The kidneys

The kidneys are a pair of organs on either side of the spine in the lower abdomen. Each kidney is
about the size of a fist. Attached to the top of each kidney is an adrenal gland. A mass of fatty
tissue and an outer layer of fibrous tissue (Gerota's fascia) enclose the kidneys and adrenal
glands.

The kidneys are part of the urinary tract. They make urine by removing wastes and extra water
from the blood. Urine collects in a hollow space (renal pelvis) in the middle of each kidney. It
passes from the renal pelvis into the bladder through a tube called a ureter. Urine leaves the body
through another tube (the urethra).

The kidneys also make substances that help control blood pressure and the production of red
blood cells.

Understanding cancer

Cancer begins in cells, the building blocks that make up tissues. Tissues make up the organs of
the body.

Normally, cells grow and divide to form new cells as the body needs them. When cells grow old,
they die, and new cells take their place.

Sometimes this orderly process goes wrong. New cells form when the body does not need them,
and old cells do not die when they should. These extra cells can form a mass of tissue called a
growth or tumor.

Tumors can be benign or malignant:

 Benign tumors are not cancer:

o Benign tumors are rarely life threatening.

o Usually, benign tumors can be removed, and they seldom grow back.

o Cells from benign tumors do not invade tissues around them or spread to other
parts of the body.
  Malignant tumors are cancer:

o Malignant tumors are generally more serious than benign tumors. They may be
life threatening.

o Malignant tumors often can be removed, but they can grow back.

o Cells from malignant tumors can invade and damage nearby tissues and organs.
Also, cancer cells can break away from a malignant tumor and enter the
bloodstream or lymphatic system. That is how cancer cells spread from the
original cancer (primary tumor) to form new tumors in other organs. The spread
of cancer is called metastasis.

Several types of cancer can start in the kidney. This booklet is about renal cell cancer, the most
common type of kidney cancer in adults. This type is sometimes called renal adenocarcinoma or
hypernephroma. Another type of cancer, transitional cell carcinoma, affects the renal pelvis. It is
similar to bladder cancer and is often treated like bladder cancer. Wilms tumor is the most
common type of childhood kidney cancer. It is different from adult kidney cancer and requires
different treatment. Information about transitional cell carcinoma and Wilms tumor is available
from the Cancer Information Service at 1-800-4-CANCER and at [Link]

When kidney cancer spreads outside the kidney, cancer cells are often found in nearby lymph
nodes. Kidney cancer also may spread to the lungs, bones, or liver. And it may spread from one
kidney to the other.

When cancer spreads (metastasizes) from its original place to another part of the body, the new
tumor has the same kind of abnormal cells and the same name as the primary tumor. For
example, if kidney cancer spreads to the lungs, the cancer cells in the lungs are actually kidney
cancer cells. The disease is metastatic kidney cancer, not lung cancer. It is treated as kidney
cancer, not lung cancer. Doctors sometimes call the new tumor metastatic or "distant" disease.
Kidney cancer: Who's at risk?

Kidney cancer develops most often in people over 40, but no one knows the exact causes of this
disease. Doctors can seldom explain why one person develops kidney cancer and another does
not. However, it is clear that kidney cancer is not contagious. No one can "catch" the disease
from another person.

Research has shown that people with certain risk factors are more likely than others to develop
kidney cancer. A risk factor is anything that increases a person's chance of developing a disease.

Studies have found the following risk factors for kidney cancer:

 Smoking: Cigarette smoking is a major risk factor. Cigarette smokers are twice as likely
as nonsmokers to develop kidney cancer. Cigar smoking also may increase the risk of this
disease.
 Obesity: People who are obese have an increased risk of kidney cancer.
 High blood pressure: High blood pressure increases the risk of kidney cancer.
  Long-term dialysis: Dialysis is a treatment for people whose kidneys do not work well.
It removes wastes from the blood. Being on dialysis for many years is a risk factor for
kidney cancer.
 Von Hippel-Lindau (VHL) syndrome: VHL is a rare disease that runs in some families.
It is caused by changes in the VHL gene. An abnormal VHL gene increases the risk of
kidney cancer. It also can cause cysts or tumors in the eyes, brain, and other parts of the
body. Family members of those with this syndrome can have a test to check for the
abnormal VHL gene. For people with the abnormal VHL gene, doctors may suggest ways
to improve the detection of kidney cancer and other diseases before symptoms develop.
 Occupation: Some people have a higher risk of getting kidney cancer because they come
in contact with certain chemicals or substances in their workplace. Coke oven workers in
the iron and steel industry are at risk. Workers exposed to asbestos or cadmium also may
be at risk.
 Gender: Males are more likely than females to be diagnosed with kidney cancer. Each
year in the United States, about 20,000 men and 12,000 women learn they have kidney
cancer.

Most people who have these risk factors do not get kidney cancer. On the other hand, most
people who do get the disease have no known risk factors. People who think they may be at risk
should discuss this concern with their doctor. The doctor may be able to suggest ways to reduce
the risk and can plan an appropriate schedule for checkups.

Symptoms

Common symptoms of kidney cancer include:

 Blood in the urine (making the urine slightly rusty to deep red)
 Pain in the side that does not go away
 A lump or mass in the side or the abdomen
 Weight loss
 Fever
 Feeling very tired or having a general feeling of poor health

Most often, these symptoms do not mean cancer. An infection, a cyst, or another problem also
can cause the same symptoms. A person with any of these symptoms should see a doctor so that
any problem can be diagnosed and treated as early as possible.

Diagnosis

If a patient has symptoms that suggest kidney cancer, the doctor may perform one or more of the
following procedures:

 Physical exam: The doctor checks general signs of health and tests for fever and high
blood pressure. The doctor also feels the abdomen and side for tumors.
  Urine tests: Urine is checked for blood and other signs of disease.
 Blood tests: The lab checks the blood to see how well the kidneys are working. The lab
may check the level of several substances, such as creatinine. A high level of creatinine
may mean the kidneys are not doing their job.
 Intravenous pyelogram (IVP): The doctor injects dye into a vein in the arm. The dye
travels through the body and collects in the kidneys. The dye makes them show up on x-
rays. A series of x-rays then tracks the dye as it moves through the kidneys to the ureters
and bladder. The x-rays can show a kidney tumor or other problems.
 CT scan (CAT scan): An x-ray machine linked to a computer takes a series of detailed
pictures of the kidneys. The patient may receive an injection of dye so the kidneys show
up clearly in the pictures. A CT scan can show a kidney tumor.
 Ultrasound test: The ultrasound device uses sound waves that people cannot hear. The
waves bounce off the kidneys, and a computer uses the echoes to create a picture called a
sonogram. A solid tumor or cyst shows up on a sonogram.
 Biopsy: In some cases, the doctor may do a biopsy. A biopsy is the removal of tissue to
look for cancer cells. The doctor inserts a thin needle through the skin into the kidney to
remove a small amount of tissue. The doctor may use ultrasound or x-rays to guide the
needle. A pathologist uses a microscope to look for cancer cells in the tissue.
 Surgery: In most cases, based on the results of the CT scan, ultrasound, and x-rays, the
doctor has enough information to recommend surgery to remove part or all of the kidney.
A pathologist makes the final diagnosis by examining the tissue under a microscope.

Treatment for kidney cancer

Staging

To plan the best treatment, the doctor needs to know the stage (extent) of the disease. The stage
is based on the size of the tumor, whether the cancer has spread and, if so, to what parts of the
body.

Staging may involve imaging tests such as an ultrasound or a CT scan. The doctor also may use
an MRI. For this test, a powerful magnet linked to a computer makes detailed pictures of organs
and blood vessels.

Doctors describe kidney cancer by the following stages:

 Stage I is an early stage of kidney cancer. The tumor measures up to 2 3/4 inches (7
centimeters). It is no bigger than a tennis ball. The cancer cells are found only in the
kidney.

 Stage II is also an early stage of kidney cancer, but the tumor measures more than 2 3/4
inches. The cancer cells are found only in the kidney.
  Stage III is one of the following:

o The tumor does not extend beyond the kidney, but cancer cells have spread
through the lymphatic system to one nearby lymph node; or

o The tumor has invaded the adrenal gland or the layers of fat and fibrous tissue that
surround the kidney, but cancer cells have not spread beyond the fibrous tissue.
Cancer cells may be found in one nearby lymph node; or

o The cancer cells have spread from the kidney to a nearby large blood vessel.
Cancer cells may be found in one nearby lymph node.

 Stage IV is one of the following:

o The tumor extends beyond the fibrous tissue that surrounds the kidney; or

o Cancer cells are found in more than one nearby lymph node; or

o The cancer has spread to other places in the body such as the lungs.

 Recurrent cancer is cancer that has come back (recurred) after treatment. It may come
back in the kidney or in another part of the body.

Treatment

Many people with kidney cancer want to take an active part in making decisions about their
medical care. They want to learn all they can about their disease and their treatment choices.
However, shock and stress after the diagnosis can make it hard to think of everything they want
to ask the doctor. It often helps to make a list of questions before an appointment. To help
remember what the doctor says, people may take notes or ask whether they may use a tape
recorder. Some also want to have a family member or friend with them when they talk to the
doctor-to take part in the discussion, to take notes, or just to listen.

The doctor may refer the patient to a specialist, or the patient may ask for a referral. Specialists
who treat kidney cancer include doctors who specialize in diseases of the urinary system
(urologists) and doctors who specialize in cancer (medical oncologists and radiation oncologists).

Getting a second opinion

Before starting treatment, a person with kidney cancer might want a second opinion about the
diagnosis and the treatment plan. Some insurance companies require a second opinion; others
may cover a second opinion if the patient or doctor requests it.

There are a number of ways to find a doctor for a second opinion:

 The patient's doctor may refer the patient to one or more specialists. At cancer centers,
several specialists often work together as a team.
 The Cancer Information Service, at 1-800-4-CANCER , can tell callers about
nearby treatment centers.
 A local or state medical society, a nearby hospital, or a medical school can usually
provide the names of specialists.
 The American Board of Medical Specialties (ABMS) offers a list of doctors who have
met specific education and training requirements and have passed a specialty
examination. Their directory-the Official ABMS Directory of Board Certified Medical
Specialists-lists doctors' names along with their specialty and their educational
background.

Preparing for treatment

Treatment depends mainly on the stage of disease and the patient's general health and age. The
doctor can describe treatment choices and discuss the expected results. The doctor and patient
can work together to develop a treatment plan that fits the patient's needs.

People may want to ask the doctor these questions before treatment begins:

 What is the stage of the disease? Has the cancer spread? If so, where?
 What are my treatment choices? Which do you recommend for me? Will I have more
than one kind of treatment?
 What are the expected benefits of each kind of treatment? Will it cure or control the
disease?
 What are the risks and possible side effects of each treatment? Will I be given anything to
control side effects?
 How long will treatment last?
 Will I have to stay in the hospital?
 What is the treatment likely to cost? Is this treatment covered by my insurance plan?
 How will treatment affect my normal activities?
  How often should I have checkups?
 Would a clinical trial (research study) be appropriate for me?

People do not need to ask all their questions or understand all the answers at once. They will
have other chances to ask the doctor to explain things that are not clear and to ask for more
information.

Methods of treatment

People with kidney cancer may have surgery, arterial embolization, radiation therapy, biological
therapy, or chemotherapy. Some may have a combination of treatments.

At any stage of disease, people with kidney cancer may have treatment to control pain and other
symptoms, to relieve the side effects of therapy, and to ease emotional and practical problems.
This kind of treatment is called supportive care, symptom management, or palliative care.

A patient may want to talk to the doctor about taking part in a clinical trial, a research study of
new treatment methods. The section on "The Promise of Cancer Research" has more information
about clinical trials.

Surgery

Surgery is the most common treatment for kidney cancer. It is a type of local therapy. It treats
cancer in the kidney and the area close to the tumor.

An operation to remove the kidney is called a nephrectomy. There are several types of
nephrectomies. The type depends mainly on the stage of the tumor. The doctor can explain each
operation and discuss which is most suitable for the patient:

 Radical nephrectomy: Kidney cancer is usually treated with radical nephrectomy. The
surgeon removes the entire kidney along with the adrenal gland and some tissue around
the kidney. Some lymph nodes in the area also may be removed.
 Simple nephrectomy: The surgeon removes only the kidney. Some people with Stage I
kidney cancer may have a simple nephrectomy.
 Partial nephrectomy: The surgeon removes only the part of the kidney that contains the
tumor. This type of surgery may be used when the person has only one kidney, or when
the cancer affects both kidneys. Also, a person with a small kidney tumor (less than 4
centimeters) may have this type of surgery.

People may want to ask the doctor these questions before having surgery:

 What kind of operation do you recommend for me? Do I need any lymph nodes
removed? Why?
 What are the risks of surgery? Will I have any long-term effects? Will I need dialysis?
  Should I store some of my own blood in case I need a transfusion?
 How will I feel after the operation?
 How long will I need to stay in the hospital?
 When can I get back to my normal activities?
 How often will I need checkups?
 Would a clinical trial be appropriate for me?

Arterial embolization

Arterial embolization is a type of local therapy that shrinks the tumor. Sometimes it is done
before an operation to make surgery easier. When surgery is not possible, embolization may be
used to help relieve the symptoms of kidney cancer.

The doctor inserts a narrow tube (catheter) into a blood vessel in the leg. The tube is passed up to
the main blood vessel (renal artery) that supplies blood to the kidney. The doctor injects a
substance into the blood vessel to block the flow of blood into the kidney. The blockage prevents
the tumor from getting oxygen and other substances it needs to grow.

People may want to ask the doctor these questions before having arterial embolization:

 Why do I need this procedure?

 Will I have to stay in the hospital? How long?
 What are the risks and side effects?
 Would a clinical trial be appropriate for me?

Radiation therapy

Radiation therapy (also called radiotherapy) is another type of local therapy. It uses high-energy
rays to kill cancer cells. It affects cancer cells only in the treated area. A large machine directs
radiation at the body. The patient has treatment at the hospital or clinic, 5 days a week for several
weeks.

A small number of patients have radiation therapy before surgery to shrink the tumor. Some have
it after surgery to kill cancer cells that may remain in the area. People who cannot have surgery
may have radiation therapy to relieve pain and other problems caused by the cancer.

People may want to ask the doctor these questions before having radiation therapy:

 Why do I need this treatment?

 What are the risks and side effects of this treatment?
 Are there any long-term effects?
 When will the treatments begin? When will they end?
 How will I feel during therapy?
  What can I do to take care of myself during therapy?
 Can I continue my normal activities?
 How often will I need checkups?
 Would a clinical trial be appropriate for me?

Biological therapy

Biological therapy is a type of systemic therapy. It uses substances that travel through the
bloodstream, reaching and affecting cells all over the body. Biological therapy uses the body's
natural ability (immune system) to fight cancer.

For patients with metastatic kidney cancer, the doctor may suggest interferon alpha or
interleukin-2 (also called IL-2 or aldesleukin). The body normally produces these substances in
small amounts in response to infections and other diseases. For cancer treatment, they are made
in the laboratory in large amounts.

Chemotherapy

Chemotherapy is also a type of systemic therapy. Anticancer drugs enter the bloodstream and
travel throughout the body. Although useful for many other cancers, anticancer drugs have
shown limited use against kidney cancer. However, many doctors are studying new drugs and
new combinations that may prove more helpful. The section on "The Promise of Cancer
Research" has more information about these studies.

People may want to ask the doctor these questions before having biological therapy or
chemotherapy:

 Why do I need this treatment?

 How does it work?
 What are the expected benefits of the treatment?
 What are the risks and possible side effects of treatment? What can I do about them?
 When will treatment start? When will it end?
 Will I need to stay in the hospital? How long?
 How will treatment affect my normal activities?
 Would a clinical trial be appropriate for me?

Side effects of cancer treatment

Because treatment may damage healthy cells and tissues, unwanted side effects are common.
These side effects depend mainly on the type and extent of the treatment. Side effects may not be
the same for each person, and they may change from one treatment session to the next. Before
treatment starts, the health care team will explain possible side effects and suggest ways to help
the patient manage them.

Surgery

It takes time to heal after surgery, and the time needed to recover is different for each person.
Patients are often uncomfortable during the first few days. However, medicine can usually
control their pain. Before surgery, patients should discuss the plan for pain relief with the doctor
or nurse. After surgery, the doctor can adjust the plan if more pain relief is needed.

It is common to feel tired or weak for a while. The health care team watches the patient for signs
of kidney problems by monitoring the amount of fluid the patient takes in and the amount of
urine produced. They also watch for signs of bleeding, infection, or other problems requiring
immediate treatment. Lab tests help the health care team monitor for signs of problems.

If one kidney is removed, the remaining kidney generally is able to perform the work of both
kidneys. However, if the remaining kidney is not working well or if both kidneys are removed,
dialysis is needed to clean the blood. For a few patients, kidney transplantation may be an option.
For this procedure, the transplant surgeon replaces the patient's kidney with a healthy kidney
from a donor.

Arterial embolization

After arterial embolization, some patients have back pain or develop a fever. Other side effects
are nausea and vomiting. These problems soon go away.

Radiation therapy

The side effects of radiation therapy depend mainly on the amount of radiation given and the part
of the body that is treated. Patients are likely to become very tired during radiation therapy,
especially in the later weeks of treatment. Resting is important, but doctors usually advise
patients to try to stay as active as they can.

Radiation therapy to the kidney and nearby areas may cause nausea, vomiting, diarrhea, or
urinary discomfort. Radiation therapy also may cause a decrease in the number of healthy white
blood cells, which help protect the body against infection. In addition, the skin in the treated area
may sometimes become red, dry, and tender. Although the side effects of radiation therapy can
be distressing, the doctor can usually treat or control them.

Biological therapy

Biological therapy may cause flu-like symptoms, such as chills, fever, muscle aches, weakness,
loss of appetite, nausea, vomiting, and diarrhea. Patients also may get a skin rash. These
problems can be severe, but they go away after treatment stops.
Chemotherapy

The side effects of chemotherapy depend mainly on the specific drugs and the amount received
at one time. In general, anticancer drugs affect cells that divide rapidly, especially:

 Blood cells: These cells fight infection, help the blood to clot, and carry oxygen to all
parts of the body. When drugs affect blood cells, patients are more likely to get
infections, may bruise or bleed easily, and may feel very weak and tired.
 Cells in hair roots: Chemotherapy can cause hair loss. The hair grows back, but
sometimes the new hair is somewhat different in color and texture.
 Cells that line the digestive tract: Chemotherapy can cause poor appetite, nausea and
vomiting, diarrhea, or mouth and lip sores. Many of these side effects can be controlled
with drugs.

Nutrition

Patients need to eat well during cancer therapy. They need enough calories to maintain a good
weight and protein to keep up strength. Good nutrition often helps people with cancer feel better
and have more energy.

But eating well can be difficult. Patients may not feel like eating if they are uncomfortable or
tired. Also, the side effects of treatment, such as poor appetite, nausea, or vomiting, can be a
problem. Some patients find that foods do not taste as good during cancer therapy.

The doctor, dietitian, or other health care provider can suggest ways to maintain a healthy diet.

Follow-up care

Follow-up care after treatment for kidney cancer is important. Even when the cancer seems to
have been completely removed or destroyed, the disease sometimes returns because cancer cells
can remain in the body after treatment. The doctor monitors the recovery of the person treated
for kidney cancer and checks for recurrence of cancer. Checkups help ensure that any changes in
health are noted. The patient may have lab tests, chest x-rays, CT scans, or other tests.

Support for people with kidney cancer

Living with a serious disease such as kidney cancer is not easy. People with kidney cancer may
worry about caring for their families, keeping their jobs, or continuing daily activities. Concerns
about treatments and managing side effects, hospital stays, and medical bills are also common.
Doctors, nurses, and other members of the health care team can answer questions about
treatment, working, or other activities. Meeting with a social worker, counselor, or member of
the clergy can be helpful to those who want to talk about their feelings or discuss their concerns.
Often, a social worker can suggest resources for financial aid, transportation, home care, or
emotional support.
Support groups also can help. In these groups, patients or their family members meet with other
patients or their families to share what they have learned about coping with the disease and the
effects of treatment. Groups may offer support in person, over the telephone, or on the Internet.
Patients may want to talk with a member of their health care team about finding a support group.

The Cancer Information Service at 1-800-4-CANCER can provide information to

help patients and their families locate programs, services, and publications.

The promise of cancer research

Doctors all over the country are conducting many types of clinical trials. These are research
studies in which people volunteer to take part. In clinical trials, doctors are testing new ways to
treat kidney cancer. Research has already led to advances, and researchers continue to search for
more effective approaches.

Patients who join these studies have the first chance to benefit from treatments that have shown
promise in earlier research. They also make an important contribution to medical science by
helping doctors learn more about the disease. Although clinical trials may pose some risks,
researchers do all they can to protect their patients.

Researchers are studying surgery, biological therapy, chemotherapy, and combinations of these
types of treatment. They also are combining chemotherapy with new treatments, like stem cell
transplantation. A stem cell transplant allows a patient to be treated with high doses of drugs.
The high doses destroy both cancer cells and normal blood cells in the bone marrow. Later, the
patient receives healthy stem cells from a donor. New blood cells develop from the transplanted
stem cells.

Other approaches also are under study. For example, researchers are studying cancer vaccines
that help the immune system to find and attack kidney cancer cells.

Patients who are interested in being part of a clinical trial should talk with their doctor.