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Here’s information that will help you to survive kidney cancer

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“I have kidney cancer. What now?”

Your doctor has just told you that you have cancer. Your mind whirls with emotion. Your spouse begins to cry. Suddenly, you are facing a health crisis. Now, more than ever, you need to think clearly despite strong emotions.

This site contains information from scientists and physicians who are experts in understanding and treating kidney cancer. The goal is to help you beat cancer by making you smarter.

How is this possible? Your ability to think, to use information, and to make choices about treatment can help bend the odds in your favor. Visiting this website is the first step.

This page provides you with brief background information about kidney cancer and some immediate resources that may be helpful and information that follows is much more in-depth, ranging from current surgical and therapeutic approaches to practical advice for living with cancer day to day.

Improving your health starts right now!

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Written by survivekidneycancer

July 14, 2010 at 11:49 PM

Posted in Kidney Cancer

Written by medical experts

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The information presented in this blog was written by medical professionals, including oncologists and surgeons, and it has been reviewed by the Nurse Advisory Board of the Kidney Cancer Association.  It is believed to be the most comprehensive and medically accurate blog about kidney cancer to be found anywhere on the web.

Questions may be directed to the staff at the Kidney Cancer Association by emailing kidney.cancer@hotmail.com.  Information on this blog is adapted, with permission, from the content of “We Have Kidney Cancer,” a 100+ page book for patients and their families that may downloaded free of charge at http://KidneyCancer.org.

Written by survivekidneycancer

July 14, 2010 at 7:35 PM

Posted in Kidney Cancer

Therapies for advanced kidney cancer

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Targeted Therapy
One of the most exciting new developments in recent years has been the introduction of drugs that interfere with the growth of cancer cells at a molecular level. By focusing on specific molecular growth pathways, these drugs can interfere with cell growth, prevent cell replication, or disrupt the blood flow supply to the cell.  Much research is under way worldwide and it is yielding new targeted therapies as well as providing information about how they work.  As more is learned about pathways of cells, it is likely that even more new drugs and treatments will be introduced.

Angiogenesis Inhibitors
For malignant tumors to expand and metastasize, they must be able to form new blood vessels by a process called angiogenesis. Tumors overproduce “growth factors” that stimulate the development of new blood vessels to supply oxygen and nutrition. These include “vascular endothelial growth factor” (VEGF) and “platelet-derived growth factor” (PDGF). These growth factors activate certain tyrosine kinases, proteins inside cancer cells that are important in cell functions, including the development of new blood vessels. This allows tumors to grow and to metastasize to other parts of the body.

In 2005 and 2006, the U.S. Food and Drug Administration (FDA) approved the first new medications to treat kidney cancer in more than a decade: sorafenib tosylate and sunitinib malate. Both of these new drugs disrupt the angiogenesis process.  Known as tyrosine kinase inhibitors, they interfere with the proteins inside cancer cells, thus interfering with certain cell functions. These drugs are also known as “multi-kinase inhibitors” because they target both the tumor cell and the tumor blood vessel structures. They work by interfering with reproduction of cancer cells as they attempt to grow and divide uncontrollably. They also have the advantage of being administered orally.

The goal of treatment with these newer medications is to slow the rate of growth of the cancer and, if possible, shrink the size of existing tumors. Some patients may experience a significant decrease in the amount of cancer in their body.  Some patients may not experience shrinkage in the size of their tumors, but have long periods of “stable” disease.  Your physician will discuss how your cancer is responding to treatment, and will have additional options to consider for treatment when necessary.  It should be noted that some patients will not receive any benefit from a medication.  In some cases, a medication that was effective in treating a patient’s cancer stops working and other treatment options must be considered.

Nexavar® (sorafenib tosylate) is a medication that targets the blood supply of a tumor, depriving it of the oxygen and nutrients it needs for growth. By blocking the vascular endothelial growth factor (VEGF) and platelet-derived growth factor (PDGF), Nexavar can interfere with the tumor cell’s ability to increase its blood supply. By blocking the Raf-kinase pathway, Nexavar can also interfere with tumor cell growth and proliferation. Clinical studies show that it can significantly slow the progression of tumors. In the Phase III trial which led to the FDA approval of Nexavar, the median time for tumor progression was doubled for patients taking Nexavar, compared with patients taking a placebo.

Sutent® (sunitinib malate) also deprives tumor cells of the blood and nutrients needed to grow by interfering with VEGF and PDGF signaling pathways. Sutent was approved by the FDA in 2006 for kidney cancer patients because of its ability to reduce the size of tumors. Clinical studies showed a favorable response rate in patients with metastatic kidney cancer whose tumors had progressed following immunotherapy.  (Download Sutent Patient Call Center brochure)

Torisel® (temsirolimus) is another recently approved kidney cancer drug.  It was designed to inhibit the mTOR (mammalian target of rapamycin) kinase, which is important in cell growth and cell survival.  By blocking the mTOR pathway, Torisel can interfere with the tumor’s ability to multiply as well as reducing its ability to stimulate angiogenesis.

Afinitor® (everolimus), approved by the FDA in March 2009, is an orally administered mTOR inhibitor. Afinitor works by blocking a specific protein known as the mammalian target of rapamycin (mTOR) and acts as a multifunctional inhibitor of cell growth and proliferation, angiogenesis, and cell metabolism. The drug is intended for those patients with advanced renal cell cancer who have already tried a kinase inhibitor, such as Sutent or Nexavar.

Votrient® (pazopanib), the sixth drug to be approved for kidney cancer since 2005, is an oral medication that interferes with angiogenesis, the growth of new blood vessels needed for solid tumors to grow. It is a kinase inhibitor indicated for the treatment of patients with advanced renal cell carcinoma.

Monoclonal Antibodies
An antibody is a protein produced by the body’s immune system that fights infections and foreign substances in the body. Monoclonal antibodies are genetically engineered antibodies that are identical copies of one another. They are used in various medical diagnostic tests and are being studied for possible use in the treatment of cancer. Monoclonal antibodies can be designed to attach to particular sites on a tumor and may be used to produce images for diagnostic purposes or to deliver anti-cancer drugs to the tumor with great specificity. The use of monoclonal antibodies in the treatment of metastatic kidney cancer is under active investigation.

Avastin® (Bevacizumab), FDA-approved for kidney cancer in August, 2009, is a biologic antibody designed to specifically bind to a protein called vascular endothelial growth factor (VEGF) that plays an important role throughout the lifecycle of the tumor to develop and maintain blood vessels, a process known as angiogenesis. Avastin is designed to interfere with the blood supply to a tumor by directly binding to the VEGF protein to prevent interactions with receptors on blood vessel cells. Avastin does not bind to receptors on normal or cancer cells. The tumor blood supply is thought to be critical to a tumorʼs ability to grow and spread in the body (metastasize).

Immunotherapy
Your body’s immune system is responsible for protecting you from viruses, bacteria, and cancer cells. Immunotherapy, sometimes called biologic therapy, is a form of treatment that boosts the body’s own immune defenses. Immunotherapy is considered one of the standard treatment options for kidney cancer patients with advanced metastatic disease.

Well-documented, but very rare, cases of spontaneous regressions in kidney cancer patients with metastatic disease suggest that the immune system can play an important role in the control and potential treatment of this disease.

The building blocks of immunotherapy are biologic response modifiers (BRMs). They are substances that enhance the body’s immune system and improve its ability to fight cancer. BRMs do their work by regulating the intensity and duration of immune responses. A BRM can be either a manmade drug or a natural substance produced by the body.

Several BRMs can boost the body’s natural immune defenses. The cytokines are an important family of BRMs that include Interleukin-2 (IL-2) and Interferons. Used either alone or in combination, they have represented the standard in the treatment of kidney cancer.

Interleukin-2 is a biologic response modifier (BRM) available for the treatment of advanced kidney cancer. It stimulates the growth of two types of white blood cells: T cells and “natural killer” (NK) cells. T cells are very important in your body’s fight against cancer because they recognize cancer cells and set off an alarm to the body. The NK cells respond to this alarm and are transformed into lymphokine-activated killer (LAK) cells, which are capable of destroying cancer cells.

Proleukin® (interleukin-2) was approved by the FDA in 1992 for the treatment of metastatic renal cell carcinoma. A genetically engineered product, recombinant IL-2, is available for use in various therapeutic regimens. Several different routes of administration may be used: IV bolus, subcutaneous (SC), and continuous IV infusion (CIV). These are further classified as high-dose (IV bolus) or low-dose (SC and CIV). The term “high-dose or IV bolus” refers to the relatively large dose of a drug given intravenously as a 15-minute infusion every 8 hours for a maximum of 14 infusions to hasten or magnify a therapeutic response.  When administered in this fashion, patients are admitted overnight to the hospital for the duration of the treatment cycle to be closely monitored.  Recent statistics on long-term survival in patients treated with high-dose IL-2 continue to demonstrate that this therapy is effective for selected patients with metastatic renal cell carcinoma who can tolerate these large doses.

These results confirm the premise that immunotherapy has curative potential in metastatic renal cell carcinoma. In some cases, IL-2 therapy produces what are known as “durable complete responses” (results lasting greater than 10 years) in a small percentage of treated patients and represented a significant milestone in the treatment of kidney cancer.  Significant toxicities are associated with IL-2 treatment. Side effects include nausea, vomiting, hypotension, cardiac arrythmias, diarrhea, loss of appetite, gastrointestinal bleeding, rashes, disorientation, hallucinations, fever, and chills.  Most of these side effects are completely reversible on discontinuation of drug administration, but they can be severe. It is imperative that the treating doctor be experienced in the use of IL-2 and ensures diligent clinical monitoring of the patient during treatment.

Interferons are widely used to treat kidney cancer, alone or in combination with other drugs. Interferon therapy is typically self-administered by injection under the skin several times per week. Interferons work by “interfering” with the life processes within the cancer cell, preventing its growth and making the cell more susceptible to attack by other elements of the immune system.

There are three major types of interferons — alfa, beta, and gamma — but interferon alfa has been most widely studied in the treatment of kidney cancer. Several interferon alfa products are available in the United States and have been used in the treatment of kidney cancer. INTRON* A, a product of Schering Corporation (Kenilworth, NJ), has been designated as interferon alfa-2b. Roferon*-A is manufactured by Roche Laboratories (Nutley, NJ) and has been designated as interferon alfa-2a. These drugs are very similar, and kidney cancer may be treated with either. Most insurance companies recognize the value of interferon alfa in treating kidney cancer and reimburse for this therapy.

In several dozen clinical trials, an overall response rate of about 13% has been achieved with interferon alfa.29 However, in patients with high performance status (i.e., lack of symptoms related to their disease), previous nephrectomy, and metastases predominantly in the lung, the major response rate (complete plus partial responses) with interferon alfa treatment is usually from 6 to 10%. It is also recognized that patients who receive interferon alpha, when compared with those who are treated with hormones or chemotherapy, have improved survival rates.

Response to interferon alfa is characterized by slow regression of tumors; the average time from start of treatment to objective response is three to four months.

The most common side effects of interferon therapy are flu-like in nature. They include fever, chills, muscle aches, headache, loss of appetite, and fatigue. Generally, these symptoms become less severe with continued therapy. Administering interferon in the evening and taking a nonprescription pain medication can help relieve these symptoms. However, other symptoms may appear with prolonged use of interferon, including weight loss, lower white blood cell counts, extra heartbeats, loss of interest in sex, mental confusion, and depression. If severe, side effects may require stopping the therapy. Fortunately, the side effects of interferon are not permanent. A dose of 5 to 20 million units of interferon alfa daily appears to have maximal efficacy and avoids the more serious toxicities associated with higher doses.

Other Treatments

Radiation Therapy
Though it is not considered a primary form of therapy, radiation can be used in the treatment of kidney cancer that has metastasized to the bone, brain or spine. It may be used to control symptoms – relief from pain, for example.

There are several different types of radiation therapy; all work on the same basic principle of using high-energy radiation to kill cancer cells or slow their rate of growth. Radiation therapy is a “localized” treatment, targeted as precisely as possible at a specific area or tumor. Radiation therapy works by damaging the DNA molecules inside the cancer cell, thereby preventing them from being able to grow and divide. Generally, this treatment is done on an outpatient basis in a hospital or clinic. The type of radiation to be used is determined by the location of the tumor in the body.

External Beam Radiation
This type of radiation therapy involves lying on a table while a machine delivers a beam of radiation from the machine, through the skin, to the tumor. The most common machine is called a linear accelerator. The exact location for the beam to “hit” is determined by calculations during the “simulation” visit prior to the initiation of radiation therapy. The radiation is given over several days (often between 4 and 14 days), with each appointment lasting about 30 minutes. The actual dose of radiation is given for seconds to minutes, but it takes time to get you and the machine set up to deliver the precise dose of radiation ordered by your doctor. The total number of days is determined by the amount of radiation that your doctor wants to use. Some areas of your body are more sensitive and will not require as much radiation as others.

External beam radiation therapy is used commonly to treat bone metastasis causing pain or areas of bone that have been weakened by the cancer (to prevent the bone from breaking). These areas include the ribs, femur (the upper leg bone), humerus (the upper arm bone), and vertebrae (your backbones). If a fracture (break) occurs, radiation therapy may be given to kill cancer cells in the bone, allowing the fracture to heal. When kidney cancer spreads to the femur or humerus, surgery may be done to insert a metal rod to stabilize the bone with radiation therapy being given following surgery.

Side Effects of Radiation Therapy

Unfortunately, radiation may also damage healthy, normal tissue. Side effects of radiation therapy occur in the area treated, referred to as the “radiation field.” These side effects are temporary and vary depending on the area of the body being treated. One of the most common side effects is dry, irritated (reddened) and sensitive skin. Your radiation oncologist or nurse will provide you with written information and instructions for skin care and other side effects specific to your radiation treatments. The skin may require 6 to 12 months to return to normal.

Constipation or diarrhea may occur if the intestines are in the “radiation field.” Anemia (low hemoglobin), neutropenia (low white blood cell count), and thrombocytopenia (low platelet count) may occur if you are receiving radiation therapy to the pelvic bones or femur. Nausea, vomiting, and urinary discomfort may also occur.

Certain side effects occur during or shortly after the completion of radiation, while other side effects may begin several weeks after you have completed radiation therapy. Fatigue may develop towards the end or shortly after your treatments have finished. Fatigue is not unusual, but it is important to discuss the timing and severity of fatigue with your doctors and nurses. Resting is important, but doctors usually advise patients to stay as active as possible.

It is important to ask questions before treatment starts, at appointments, and during your recovery from radiation in order to ensure that your treatments are effective, side effects are minimal, and that any side effects that develop can be treated early. All of these factors will help you tolerate the treatment with a minimum of side effects and complications.

Radiosurgery

Radiosurgery is non-surgical technique that allows treatment of cancer that has metastasized to the brain. Doctors direct beams of high-dose radiation to tumors. This allows for a more precise and concentrated treatment than other types of radiation. Radiosurgery is the preferred method of treating brain tumors under a certain size and number.

One form of radiosurgery is gamma knife therapy for brain metastases. This is an outpatient procedure done in a gamma knife center, using a fitted head frame and both a CT and MRI scanner. The patient lies on a bed wearing the fitted head frame (helmet) that slides into the gamma knife machine. Radiation is delivered through ports inside the helmet, with the beams intersecting at the tumor.

Chemotherapy
Chemotherapy works on the same principles as radiation therapy except that chemicals are used to kill malignant cells or slow their growth. The specific type of chemotherapy depends on the site of metastases, type and grade of tumor, and physical condition of the patient. Many chemotherapy programs combine several different drugs to kill malignant cells that might be resistant to a single drug. Chemotherapy may be administered in a hospital or on an outpatient basis. The drugs may be taken by mouth, by intravenous infusion, or by simple injection.

Although chemotherapy is the standard treatment for most solid tumors, kidney cancer is generally resistant to chemotherapy.35 The reason for the resistance of kidney cancer cells to chemotherapy is not completely understood. However, it is now known that kidney cancer cells produce an overabundance of multidrug-resistance-associated protein, which acts to repel various chemotherapeutic agents away from the cancer cell.

5-Fluorouracil (5FU) appears to be the most effective chemotherapeutic agent currently available for kidney cancer, but response rates are only in the range of 5% to 8%.36 Therefore, at present, chemotherapy is generally used in combination with other therapies or reserved for patients entering clinical trials to test new agents and for patients who failed to respond to immunotherapy.37 Researchers continue to study new drugs, new drug combinations, and new treatment approaches.

As in radiation therapy, chemicals can damage normal cells. As a result, patients may experience side effects such as nausea, vomiting, diarrhea, rash, allergic reactions, and low white blood cell counts. The severity of these side effects depends on dosage, the specific drug used, the patient, the course of treatment, and other factors. These effects may last for a few hours to a few days.

Hormone Therapy
Hormone therapy is a form of chemotherapy; however, in this case natural and synthetic hormones are used in place of cytotoxic drugs. There are generally fewer side effects from this type of therapy. Unfortunately, to date the use of hormonal therapy in the treatment of metastatic kidney cancer has yielded disappointing results.36 Hormone therapy is generally used to treat symptoms of the cancer rather than the cancer itself in a small number of patients with advanced kidney cancer.38 Megace (medroxyprogesterone) is an oral hormonal agent which may be used to help treat cancer-related anorexia, or loss of appetite.

Investigational Therapies

Vaccine Therapy

Vaccine therapy is an experimental treatment that uses the patient’s own tumor cells or tumor-associated products to vaccinate the patient. The goal is to boost the body’s immune system in order to fight cancer. Unlike other vaccines, which are preventative, cancer vaccines are therapeutic; that is, they treat the disease rather than prevent it. Once you have had surgery to remove a tumor, a portion of it is used to create a vaccine that is then re-introduced into the body. It is hoped that these naturally occurring substances will stimulate the immune system to attack any new cells that re-appear bearing the original tumor’s genetic code. Vaccine therapy using tumor cells should be discussed as a treatment option before your nephrectomy.

Vaccine therapy is still in an investigational stage, with numerous research programs in progress. Early results were mixed, but as techniques have evolved, results have become more promising.  Oncophage®, a vaccine manufactured by Antigenics, is approved for use in Russia, but has not been approved by the FDA.

Stem Cell Transplants
Blood stem cells reside in the bone marrow and perform the critical role of continually replenishing the body’s supply of red blood cells, white blood cells, and platelets. When transplanted, stem cells and T-Lymphocytes can elicit an anti-tumor effect under certain conditions.

This is a highly experimental procedure, and patients with advanced metastatic cancer who did not respond to interferon alfa K2 therapy have been treated with transplantation of peripheral blood stem cells.51 The results of this approach remain experimental, and because of the serious side effects experienced by some patients, further refinement of the procedure is needed.

Stem cell transplantation is an intensive procedure and is only recommended in limited situations. Check with your doctor.

Managing Your Expectations of Therapy

As you and your medical team consider options, including all of the treatment therapies listed here, it’s important to keep all of these options in perspective. Your doctor will make a recommendation to you based on a number of factors. It is important to understand why a particular treatment is chosen, so be sure to ask questions.  If you are unable to afford these treatments, financial help is available.  Call +1 847-332-1051 for information.

The state of your disease will be followed through the use of scheduled CT scans. Your doctor will discuss your results with you, indicating whether the tests show stabilization, partial response, complete response, or progression of the disease.

Each of us wants and needs to believe that we will be helped and “cured” by whatever therapy is used. The information you receive may cause disappointment. However, make certain that you talk to your doctor to ensure that you understand the meaning of terms like “partial response” and “stable disease.” These should be viewed as partial successes, not failure. Partial responses can help you determine when to change therapies — sometimes leading to other options that are more beneficial. Even if there is no response to a given therapy – a condition known as “stable disease” – this may put you in a holding pattern until a newer treatment or clinical trial is available.  Kidney cancer is too unpredictable, and the therapies are too new, for you to give up fighting because of “stable disease” or “partial response.” For this reason, it is important not to let disappointment rob you of your determination or will to live. Simply learn from your experience and go on.

Written by survivekidneycancer

July 14, 2010 at 7:25 PM

Posted in Kidney Cancer

Understanding the various surgical approaches to the most common form of kidney cancer

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Traditional Surgery: Removing All or Part of the Kidney

Treatment of most kidney cancers begins with removal of the primary tumor in an operation called a nephrectomy. The purpose of surgery is to remove the primary tumor and involved tissue in the kidney. Even if cancer has already spread, a nephrectomy may still be beneficial because your body then has less cancer to fight through treatments that your doctors might recommend after surgery. In fact, a recent study of 245 patients with operable metastatic kidney cancer demonstrated that patients who had a nephrectomy before systemic therapy with interferon alfa had a higher survival rate than patients treated with interferon alfa alone.

A nephrectomy is a well-defined and common operation. Thousands of nephrectomies are performed every year for kidney cancer as well as for other diseases. Although it is a major surgery, the potential risks are well defined and it is usually quite safe if you do not have any underlying illnesses, such as heart disease or liver disease. Mortality rates are typically less than 1% for patients whose cancer has not metastasized and around 1% for patients with metastatic disease.  Complications are not common unless the tumor is locally advanced, such as when the tumor extends into the renal vein or inferior vena cava (the large vein through which blood from your legs and internal organs returns to the heart), or the tumor has spread beyond the kidney. Extension of the tumor into the vein requires blood vessel surgery to remove the affected portion of the vein. This problem is well understood, but it prolongs the operation, and blood transfusions are often needed. Blood transfusions may not be required for smaller, localized tumors.

Though nephrectomy is the most common treatment for kidney cancer, it is important to note that in some cases it may not be appropriate. Your oncologist and/or urologist will explain the factors that influence the decision on whether to proceed with a nephrectomy.

There are 2 basic types of nephrectomies for kidney cancer. In an open partial nephrectomy, the surgeon removes just the part of the kidney that contains the tumor. An open radical nephrectomy involves removal of the entire kidney, and often includes the adrenal gland above the kidney, the surrounding fatty tissue, and the lymph nodes adjacent to the kidney.

Most often, the surgeon will perform a radical nephrectomy because it is more effective in eradicating the cancer. However, partial nephrectomy can often achieve the same results in patients with smaller cancers. Partial nephrectomy is particularly indicated in patients with either kidney failure or a problem with the opposite kidney.  The size of the tumor can also determine whether a partial nephrectomy is performed.  Partial nephrectomies are sometimes associated with their own set of complications, including temporary shutdown of the kidney or prolonged drainage of urine, but these are usually related to the size and location of the tumor. In the past, partial nephrectomy was used only when a patient had a solitary (only one) kidney, but it is considered safe enough now that it is often appropriate for a patient who has a normal kidney on the other side.

A radical nephrectomy requires more extensive surgery. The adrenal gland, which is located immediately above the kidney, is often removed during a radical nephrectomy. It may be appropriate to leave the adrenal gland behind, however, especially when the tumor is relatively small or located in the lower portion of the kidney.  Partial or complete removal of the lymph nodes during surgery also may be helpful to determine if the tumor has spread, but again, this decision depends on a variety of factors. A pathologist will examine the lymph nodes under a microscope to see if any kidney cancer cells are present in the lymphatic system.

Laparoscopy and Kidney Cancer

Open radical or partial nephrectomies – performed through a typical surgical incision — are the most common surgical techniques used to remove a diseased kidney. Recently, however, less invasive surgical techniques have been developed and are gaining increasing acceptance. These are now referred to as “minimally invasive surgeries,” and involve the use of a laparoscope, an instrument that is passed through a series of small incisions or “ports” in the abdominal wall. Laparoscopy, which is sometimes called “band-aid surgery,” can be used for both radical and partial nephrectomies and accomplishes the same things as traditional surgical techniques.

Laparoscopic radical or partial nephrectomy can result in decreased blood loss, a shorter hospital stay, less need for narcotic pain medication and shorter recovery time when compared with open radical nephrectomies.

Most medical centers and many surgeons offer laparoscopic radical nephrectomy. But the use of laparoscopic instrumentation can be technically difficult. Therefore, hand-assisted techniques have been developed to facilitate the procedure in select cases. Surgeons sometimes make a short incision in conjunction with the instrument ports in order to insert one hand to assist the laparoscopic maneuvers. Hand-assisted laparoscopy may make laparoscopic nephrectomies more widely available while maintaining the benefits of minimally invasive surgery.

Laparoscopic partial nephrectomies can be done, too, but they are performed by a much more limited number of surgeons at the present time because of the technical expertise and experience required.

Laparoscopy has also been successfully combined with two other surgical techniques, called cryosurgery and radiofrequency ablation (RFA), to destroy small kidney tumors in select patients. Cryosurgery, or cryoablation, uses freezing temperatures (achieved by using liquid nitrogen or carbon dioxide) to destroy diseased tissue. RFA destroys tumors with thermal energy (heat). In selected patients, these procedures can also be done by passing tiny probes directly through the skin into the tumor under x-ray guidance, without an incision.

All of these laparoscopic procedures hold much promise but may not be suitable for all patients. The long-term safety and results of these techniques remains to be determined. Ask your doctor what surgical technique is best for your particular case.

The Role of Nephrectomy in Advanced Disease

Nephrectomy has become an integral part of the management of patients with metastatic kidney cancer.  In the past, nephrectomy was performed in this setting only in certain circumstances – mostly to relieve pain or as a response to intractable bleeding. But indications that some patients had spontaneous regression of their metastatic disease following nephrectomy, and the fact that the primary tumor rarely, if ever, responded to systemic therapy, prompted more widespread integration of nephrectomy into the management of patients with metastatic disease.

Performing nephrectomy in patients with advanced kidney cancer is not without risk, however.  The very real chance of significant metastatic disease progression during the postoperative period or complication before or during surgery that may prolong postoperative recovery could potentially delay or prevent the administration of systemic therapy in the postoperative period.  Patient selection for surgery remains critical for success.  Patients should be good candidates for surgery, and have a relatively small tumor that can be impacted significantly by surgery.  Patients with complicating factors, including extensive metastases to the liver, brain, or bones, may not be good candidates for surgery because of their poor overall prognosis.

Arterial Embolization

A procedure called arterial embolization is sometimes used before an operation to make surgery easier. Small pieces of a special gelatin sponge or other material are injected through a catheter to block the artery that feeds the tumor-containing kidney. This procedure can shrink the tumor by depriving it of the oxygen and nutrients it needs to grow and may reduce bleeding during the operation. It is also used to provide relief from pain or bleeding when surgical removal of the tumor is not an option because of poor health or other reasons.

How to Think About Your Tumor

Your tumor and the removed tissue may be important – both to you as a cancer patient and for cancer research in general. The tumor and other tissues that are removed surgically provide potentially important information to your doctors about your specific cancer that may help estimate your risk of relapse, help guide further treatments or contribute to research. For example, the tumor is a storehouse of white blood cells and various other constituents of the immune system that your body has recruited to fight your cancer. In some cases, always as a part of a research protocol, the tissue may be used to prepare a vaccine or may be saved for other purposes. Not surprisingly, tissue will not be available if your tumor is destroyed by cryosurgery or RFA.

Some promising new therapies use material extracted from the surgically removed tumor to fight any malignant cells left behind. (These promising new therapies include adoptive immunotherapy and vaccine therapy and are discussed later in this book.) It is important to note that many of these therapies are investigational. Before surgery, you should discuss with your doctor what the most appropriate use of your tissue should be after it is removed. If your doctor approaches you about saving blood samples and tumor tissue, be sure to listen carefully and consider what he is asking. At present, there is no reason to routinely save tissue. You should consult your doctor for a recommendation.

Before the Operation

If your doctor recommends a nephrectomy, you will probably have lots of questions and concerns. Be sure to share these with your doctor. You will want to know where the surgery will be performed and who the surgeon will be. Your surgery should be performed in a hospital or medical center that is experienced in dealing with kidney cancer. Your surgeon should be a board-certified urologic surgeon. If you do not know whether your hospital or doctor meets these requirements, ask questions before scheduling or agreeing to surgery. No one will be offended by your prudence. You may also want to know how you will feel after the operation and how any pain you might experience will be addressed. You may want to know when you can resume normal
activities and what kind of follow-up treatment is planned. Getting answers to these questions can help relieve or reduce your anxiety so you can focus on healing and fighting your cancer.

The Day before Surgery

Your surgeon may want you to check into the hospital the day before surgery, however, it is becoming more common to admit patients on the day of surgery. On this day, some simple final tests will be performed. These tests are done primarily so that your anesthesiologist has information on how much anesthetic gas to give you during the operation. You may also be required to take a laxative and to drink fluids to flush out your bowels; to reduce the risk of infection during surgery, your surgeon does not want you to have anything in your stomach or intestines. You may also be asked to wash your body with special antibacterial soap. Men are advised to shave on the night before. You won’t get a chance to shave for several days after surgery, and there’s no point to having an itchy beard or face.

Even if you are a sound sleeper, you’ll probably be a little anxious the night before surgery. You may be offered a sleeping pill to make sure you get a good night’s rest before surgery. Take it without worry.

The Day of Surgery

If your surgery is scheduled to start in the morning, you will be awakened early. You may be asked to take an antibiotic and mild sedative. You will be wheeled on a gurney or in a wheelchair down to surgery.

When you arrive in the “pre-op” area, the anesthesiologist will prepare you for surgery. Different anesthesia techniques can be used to keep you free from pain. One common technique involves the use of an epidural catheter to administer a direct flow of anesthetic to your nervous system. This process usually starts with an injection of a local anesthetic into your back, followed by the insertion of a catheter into your back at the spine, just above your kidneys. The catheter is connected with a thin plastic tube to a pump that will give you small injections of anesthetic to prevent any pain. By administering a small, precise dose at frequent, predetermined intervals, the anesthesiologist can achieve greater safety and pain relief. Less anesthetic is administered and there are few, if any, side effects. (This system is also widely used for childbirth.)

You will be transported into the operating room and the anesthesiologist will put you to sleep using a combination of anesthetic gases. The surgery will begin. You will be totally asleep and have no awareness of pain during surgery.

After the surgeon has completed the procedure and the incision is closed and bandaged, you will spend some time in a surgical recovery room. You will be carefully watched and you will slowly wake up as the effects of the anesthetic gases wear off.

You will also be very “mellow” from the medications used to control surgical pain. Your surgeon will want you to have as little pain as possible because if you are comfortable, you will heal better. Try to relax and sleep.

If your surgery has been extensive, you may be put in an intensive care room where your recovery can be closely monitored for several days. You probably won’t remember the operation or going to the recovery room. Your first recollection will probably be waking up in your hospital room or in intensive care.

If you are in intensive care when you wake up, you may be surprised if you have not seen an intensive care room before. The IV bottles, the oxygen tubes, electronic heart monitors, and other gear are there for only one reason — your safe recovery. Though they are distracting, they play an important role in your recovery.

In the intensive care unit, you will be closely watched by nurses and doctors. In some hospitals, you may even have nursing staff assigned exclusively to you 24 hours per day. Your blood pressure and temperature will be checked hourly. Samples of your blood will be drawn frequently. Certain drugs may be administered to help your safe recovery.

If you want something or feel uncomfortable, communicate your needs to the hospital staff. They are there to help you. Depending on the hospital and your condition, you may be allowed to have visitors while you’re in intensive care. Generally, visits are limited to your immediate family and only during certain hours. However, as a consequence of your medication, your visitors should not expect you to engage in much conversation. Don’t expect to remember the details of your conversations while you’re in the intensive care unit. It may also be upsetting for some family members to visit you in intensive care, particularly because they may not understand that all the tubes and wires are there to help you get better and serve a medical purpose. The best policy may be to tell the hospital staff to restrict your visitors until you are feeling better.

A Few Days after Surgery

After 2 or 3 days in your room, you will advance to the next stage of recovery. The various tubes and other support equipment will be removed. You may be allowed to have more visitors. You will be able to read, listen to music, watch television, and take telephone calls.

Your doctors will visit regularly to check your medical condition. Medical staff will check your incision and change the bandage. You will also be told the first results of pathology tests run on the tissue that the surgeon removed. These tests will indicate the type of tumor, whether the tumor had spread, and other facts that are important for you to know. If you have questions, don’t hesitate to ask your doctor.

About 4 or 5 days after your operation, the way you are given pain medication will change and the epidural catheter in your back will be removed. Milder pain medications may be given by intravenous injection and/or orally. Some of these medications, particularly oral pain relievers, may cause constipation. If so, mention this problem to your doctor. He or she may decide to switch your medication or give you something to relieve your constipation.

Exercise is an important part of recovery. It improves your circulation and respiration, and helps prevent blood clots in your legs. The day after surgery, you will be asked to get out of bed and perhaps do some walking. Getting out of bed may not be easy at first, although walking or shuffling along may be no problem. Getting into and out of bed is difficult because during a full, open nephrectomy, the surgeon may need to cut through your flank muscles. He or she may also have removed one or more of your ribs. During surgery, your cut muscles and tissues were sutured back together internally before the incision was closed by stapling or stitching your skin. When you perform complex movements like getting into and out of bed, these muscles may hurt, strain against their internal sutures, and prevent the freedom of motion that you are used to. When the muscles are healed, you’ll feel much better. Despite any discomfort, get out of bed and walk. It’s good for you.

About 3 or 4 days after surgery, you may get some solid food to eat. You will rejoice! Take care to eat well. Your body will be rebuilding muscles and other tissues. Good nourishment will help the healing process.

Going Home About 1 week — or even less — after surgery, the surgical staples or sutures will be removed from your incision. This removal does not hurt. The incision will be lightly bandaged. You will be discharged and sent home to recover. You will still be taking medications to relieve pain and a prescription sleeping medication to help you sleep at night. You will still find it difficult to get into and out of bed by yourself because your back muscles are still healing. You may find it most comfortable to sit in a soft chair or even sleep in a chair, preferably one with strong arms so you can help yourself into and out of it.

It is a good idea to get some walking exercise every day. You won’t be able to do any physical work or lift much weight. Take advantage of this time to relax. There isn’t much you can do to speed up the healing process, so don’t aggravate yourself. One word of caution — a real belly laugh can hurt, so be careful of funny movies and excessive humor.

Depending on the type of dressing used to bandage the incision, you may be able to take a shower. If a shower is not possible, take regular sponge baths. Try to take good care of yourself. It will make you feel better.

Your surgeon will probably want you to visit his or her office about 2 weeks after going home. The purpose of this visit is to check the healing of your incision, follow up for complications, conduct blood and urine tests, and check your general health. If you are having any problems or feel something isn’t going right, be sure to discuss these concerns with your doctor.

After about 3 weeks, you may return to work with your doctor’s permission if you are feeling up to it. But you still need to take things slow and easy. It takes a full 3 months for your muscles to heal and for you to regain your strength.

About 2 months after your surgery, you can start doing more exercises. Build up to the level of exercise that effectively works different muscles but is still comfortable for you. Exercise will help restore your muscle tone and your energy level.

The recovery process described above is typical for open radical nephrectomies. With the newer laparoscopic procedures, recovery times may be considerably shorter. For example, in one study, 24 patients experienced a 64% more rapid return to normal non-strenuous activity after laparoscopic surgery than with open surgery.  It’s always a good idea to ask your doctor’s advice before resuming exercise after surgery. Your doctor may have a procedure that is different from other doctors — and it may be dependent on the extent of your surgery.

Prognosis The good news is that survival rates for kidney cancer have improved, as they have for all types of cancer. The probability of long-term survival depends on a combination of factors, particularly the spread of the tumor as defined by stage. About half of all patients have localized disease (Stage I or II) and have a good prognosis for long-term survival.

Survival is also determined by the grade level of your tumor, TNM stage and performance status. The grade refers to how closely the cancer cells look like normal kidney cells. Tumor grade is defined by the size and density of cancer cell nuclei, as judged by pathologic microscopic evaluation. Renal cell cancers are graded on a scale of 1 through 4. More information about the grading and staging of kidney cancer can be found in Chapter 2 of this book.

Grade 1 cells are most like normal cells. They often grow slowly, and patients with grade 1 cells generally have a good prognosis. At the other extreme, grade 4 cells are very different from normal cells. They are more invasive and more likely to metastasize. As tumor spread increases, so does the probability of lymph node involvement and the chance that malignant cells will be carried to other parts of the body.

Despite the statistical research on survival, be careful not to generalize from average survival summaries to your own case. Survival statistics vary from study to study. Many survival studies have used small samples so the results may not be applicable to larger patient populations. Moreover, no kidney cancer case is average. Every case is unique. These facts cannot be emphasized too much.

Your probability of long-term survival will depend on the stage and the type of tumor, your age and physical condition, what follow-up and treatment you receive after your nephrectomy, and a host of other factors. You should discuss your survival prognosis with your doctor, because he or she is most familiar with the unique medical characteristics of your case. But don’t be surprised if your doctor is reluctant to give you an exact answer. Your doctor is aware of the many variables that can affect survival and knows that there is no precise answer.

You should also keep this last thought in mind: the longer you survive, with or without disease, the better your chances of receiving a new, more effective treatment. Significant advances have been made in the past 2 decades and much exciting research is being done at this very moment. The longer you stay alive, the more benefit you may get from this research.

Medical Follow-Up After nephrectomy, you should have frequent medical check-ups. How often and what tests are scheduled will be determined by your doctor based on your situation at the time of diagnosis, the pathology of your particular tumor, and other factors. Your doctor may schedule regular diagnostic tests. If after a period of several years no more cancer is evident, your doctor may decide to reduce the frequency of these tests.

Just as the stage of your cancer (I, II, III or IV) helps determine the treatment options that will be considered by your health care team, it also affects the follow-up care that you will receive following your initial treatment.

In general, the higher your stage of cancer at the time of initial treatment, the more aggressive your follow-up care will be. The frequency of doctor visits, for example, will be higher for Stage III patients than it is for Stage I patients. Follow-up procedures may also be more intense; for example, a simple chest x-ray may suffice as a check up for early-stage patients, but a CT scan may be necessary for later-stage patients.

Often Stage I and II patients receive no other treatment than close follow-up care. Patients with Stage III disease may be treated with more aggressive follow-up that includes some form of additional treatment – known as adjuvant therapy (see below). Patients with Stage IV disease are almost always treated with aggressive follow-up that includes some form of additional treatment.

During your follow-up period, you should watch for the unique signs and symptoms that occurred when you first noticed the disease. For some people, certain symptoms or blood test abnormalities may be useful indicators of recurrent disease.

You should also keep a journal of your aches and pains and any other physical ailments you experience. Bring your journal to your check-ups. If you experience any unusual pains or symptoms between check-ups, call your doctor. If something is wrong, you will get help sooner. If nothing is wrong, you will have peace of mind after talking to your doctor. Even if your prognosis is excellent, you and your doctor should be vigilant. If any metastases occur, you want to catch the problem early and treat it promptly because immediate attention will prolong your survival.

Things to Look for Between Check-ups Your doctor does not work alone in keeping you healthy. He or she relies on you to discuss any problems you have. If you experience any of the following problems, be sure to call them to your doctor’s attention: weight loss, loss of appetite, weakness, headache, changes in your mental status, fevers or high temperature, abdominal or skeletal pain, cough, shortness of breath, enlarged lymph glands, or blood in your urine. Be careful. Do not dismiss symptoms of illness as unimportant. Your doctor will not criticize you for being cautious.

Treatment of Metastatic Disease

If there is no evidence of metastases after your nephrectomy, your doctor may decide, based on current medical information, that no additional treatment is necessary beyond medical check-ups. However, if you do fall into the category of “high risk” recurrence, you might require additional treatment – known as adjuvant therapy — after your nephrectomy. The most commonly used treatments for kidney cancer are immunotherapy, vaccine therapy, or target therapy. These treatments, though quite different from one another, will be part of a clinical trial since their effectiveness in preventing your disease from coming back is being studied.

Many patients ask about the use of radiation or chemotherapy as a treatment for their kidney cancer. It’s important to note that kidney cancer is not as responsive to these therapies as other forms of cancer are; thus radiation and chemotherapy are not used as primary treatment.

Summary

For most kidney cancer patients, nephrectomy will be a part of your recovery plan. This surgery is performed thousands of times every year and is quite safe and effective. New advances in surgical technique offer less invasive forms of the surgery and shorter hospital stays. If your cancer is treated by surgery early enough, complications are few and prognosis may be good. For patients with more advanced-stage cancer, additional treatment may be required; still, surgery remains the cornerstone of kidney cancer treatment.

Written by survivekidneycancer

July 14, 2010 at 7:24 PM

Posted in Kidney Cancer

Detection, Diagnosis and Staging

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Because kidney cancer may spread to other parts of your body, it is important to be very thorough in testing for its presence. Your doctor may order some or all of a variety of tests that are available to determine the extent of your cancer and to develop your treatment plan.

Your doctor may use different approaches to diagnose RCC, depending on the symptoms you display. All approaches begin with a careful physical examination, combined with a complete discussion of past and present medical problems.

Certain tests may be done to assist your doctor in determining the correct diagnosis. The most common tests that may be ordered include:

Computed Tomography (CT scan)

A CT scan is a highly specialized x-ray that is used to visualize internal organs and provides a very accurate cross section picture of specific areas of the body.  It is used as one of the primary imaging tools for the assessment of RCC. If the initial sign of the tumor is a mass or thickening in the kidney area detected on an x-ray taken for other reasons, or seen or felt from the outside of the body, a CT scan is often ordered.

CT scans are more detailed then ordinary x-rays, taking pictures of your organs one thin slice at a time from different angles. Then a computer puts the images together to show the size and location of any abnormalities. To enhance the image of the abdominal organs, dye may be taken orally (by mouth) before the scan. An IV may also be placed for injection of additional contrast dye. There is generally no pain associated with the CT scan, although the IV dye may cause a hot flushing sensation. Some people may also experience an allergic reaction to IV dye (also called IV contrast), especially individuals who are allergic to iodine. Depending on the part of the body visualized, dietary restrictions may be required prior to the procedure.

CT scanning technology has recently been improved by development of a method called spiral CT scanning.  This type of CT scan is faster and gives a better image than older CT methods.

Magnetic resonance imaging (MRI)

An MRI is a highly specialized scan that is similar to a CT scan, but may be better suited for assessing certain areas of the body, such as the bones. It creates an accurate cross-section picture of specific organs within the body, to allow for a layer-by-layer examination. An MRI is usually not a painful procedure. Because it uses a powerful magnet to produce the images, people with metal within their body — such as prosthetic hip replacements, pacemakers, or metal plates — should discuss the use of an MRI with their physician and the MRI technician before the scan is performed. The test may require the patient to lie still for a long time usually in a narrow space, which may be difficult for some people who do not like closed in spaces. MRI scans are often used in cases where CT scans may not be able to view an area of the body well enough.

Bone scan

A bone scan is used to check for the spread of cancer to the bones.  It is done by injecting small amounts of a special radioactive material through a vein into your bloodstream. This material is carried to the bone, where it collects in areas where there is a lot of bone activity. The test can identify both cancerous and non-cancerous diseases but the test can’t distinguish between cancer and other conditions such as arthritis when used it is used alone. Therefore other tests may be needed, such as x-rays or CT scans.

PET scan (Positron Emission Tomography)

A PET scan is a very specialized diagnostic study that provides information about how extensively a cancer has spread, based on certain activities of the cells. PET scans are typically used for breast, colorectal, ovarian, lymphoma, lung, melanoma, and head & neck cancer. The effectiveness of PET scans for kidney cancer is still being studied.

Unlike CT and MRI scans, which produce images of internal organs or other structures, a PET scan produces images based on the chemical and physiological changes related to a cell’s metabolism. This is important because chemical and physiological changes in the cells often occur before structural changes in tissues can be seen. The result is that PET scans can help distinguish benign from malignant tumors and help doctors determine the stage of cancer spread in the patient. PET scans can also measure whether or not treatment therapies are working. PET scans are quite often used in combination with CT and MRI scans. A PET scan can last from 15 minutes to 2 hours, depending on the area of the body being scanned.

Ultrasonography (ultrasound or US)

If there is blood in the urine, an ultrasound of the abdomen with special attention to the kidneys, ureters, and bladder may be ordered. Usually no preparation is needed for this test, and it is generally not uncomfortable. It utilizes sound waves to produce images of internal organs, helping the radiologist detect any masses that may be present. A wand called a transducer is passed over the skin, and emits sound waves that are detected as echoes bouncing back off internal organs. The echo-pattern images produced by kidney tumors look different from those of normal kidney tissue. This test may be used for initial diagnosis of a kidney mass or to help visualize a mass when a fine needle biopsy is done (see Biopsy Procedure).

Intravenous pyelogram (IVP)

An intravenous pyelogram (IVP) test may also be used. Special dye is injected into a blood vessel, usually in the arm. The dye circulates through the blood stream to the different organs of the body including the kidneys. X-rays are taken of the kidneys as the dye circulates through them. This will identify any abnormalities within the kidney. If either the ultrasound or IVP is abnormal, a CT scan may be ordered.

Chest x-ray

A plain x-ray of the chest may be done to see if the cancer has spread to the lungs. If something is seen on the x-ray, the doctor may order a CT scan of the chest to help determine what it is.

Angiography

This procedure is used to visualize location and function of arteries. A catheter is usually threaded up a large artery in the leg into an artery leading to your kidney (renal artery). A contrast dye is then injected into the artery to outline blood vessels. Angiography can outline the blood vessels that supply a kidney tumor, which can help a surgeon better plan an operation. Angiography may also help diagnose renal cancers since the blood vessels supplying tumors usually look different than the normal blood supply to the kidney.

Biopsy Procedure

If, after diagnostic tests are completed, there is a strong clinical suspicion that the kidney mass is cancerous (malignant), surgical removal of the kidney (nephrectomy) will be performed immediately. If the diagnostic test results are not clear, a biopsy may be performed. During a biopsy procedure a small sample of tissue is removed from the mass and examined to determine whether it is benign or malignant. There are several ways to perform a biopsy of a kidney mass, though the most common method is a procedure called a fine needle aspiration (FNA) or fine needle biopsy. Using ultrasound or a CT scanner for guidance, the doctor will insert a long thin needle through the skin, directly into the mass, and remove the sample tissue. This is generally not an uncomfortable procedure.  A pathologist will evaluate the biopsy tissue under a microscope to determine whether it is benign or malignant. If it is malignant, the pathologist also will identify the histology, or cell type.

If there is clear evidence of widespread metastasis at the time of the discovery of the kidney mass, a biopsy may be taken from an area of metastasis, instead of from the kidney. This may be recommended to reduce risk of bleeding, if the metastatic area is more easily accessible than the kidney.

Other Tests

In addition to the tests described above, your doctor may order one or more of the following lab tests to complete your evaluation.

Urinalysis

Urinalysis is usually part of a complete physical exam. Microscopic and chemical tests are performed that will detect small amounts of blood and other substances not seen with the naked eye.  About half of all patients with renal cell cancer will have blood in their urine. Microscopic examination of urine samples (called urine cytology) can also detect cancer cells in the urine.

Blood tests

A complete blood count and chemical test of the blood can detect findings associated with RCC. Anemia (too few red blood cells) is very common. Erythrocytosis (too many red blood cells) may also occur because some of these renal cancers produce a hormone (erythropoietin) that can increase red blood cell production by the bone marrow.

High levels of liver function enzymes in the blood (for reasons not known) and hypercalcemia (high calcium levels) sometimes occur.

The Role of Staging and Grading

Staging of a cancer is the process of classifying how far a cancer has spread, while grading determines the characteristics and make up of the cancer’s cells. The two systems play different roles, but both staging and grading are important predictors of the course of the disease and treatment effectiveness (prognosis). They are useful tools in determining what therapy is appropriate and the chance of treatment success.

Staging

Certain imaging tests, including CT and MRI scans, can help determine staging. Blood tests will also be done to evaluate your overall health and to detect whether the cancer has spread to certain organs.

A staging system is a standardized way in which the cancer care team describes the extent of the cancer. The most commonly used staging system was developed by the American Joint Committee on Cancer (AJCC)

American Joint Committee on Cancer (AJCC) TNM Staging System

The AJCC staging system is based on the evaluation of the tumor size on the kidney (T), the number of lymph nodes (N) and the extent of metastisis (M). Evaluation of the T, N and M components is followed by a stage grouping.

The T component designates the size of the tumor. The numerical value increases with tumor size and extent of invasiveness. The letter T followed by a number from 0 to 3 describes the tumor’s size and spread to nearby tissues. Some of these numbers are further subdivided with letters, such as T1a and T1b. Higher T numbers indicate a larger tumor and/or more extensive spread to tissues near the kidney.

The N component designates the presence or absence of tumor in the regional lymph nodes. In some sites there is an increasing numerical valued based on size, fixation, or capsular invasion. In other sites, numerical value is based on multiple node involvement or number of location and the regional lymph nodes. The letter N followed by a number from 0 to 2 indicates whether the cancer has spread to lymph nodes near the kidney and, if so, how many are affected. Lymph nodes are bean-sized collections of immune system cells that help fight infections and cancers.

The M component identifies the how distant the spread of the cancer has been, including lymph nodes that are not in the region of the original tumor. The letter M followed by a 0 or 1 indicates whether or not the cancer has spread (metastasized) to distant organs such as the lungs or bones, or to lymph nodes that are not near the kidneys.

Detailed Definitions of T, N, and M Categories

Primary tumor (T)

TX: Primary tumor cannot be assessed (information not available).
T0: No evidence of a primary tumor.
T1a: Tumor is 4 cm (about 11/2 inches) in diameter or smaller and is limited to the kidney.
T1b: Tumor is larger than 4 cm but smaller than 7 cm (about 2¾ inches) and is limited to the kidney.
T2: Tumor is larger than 7 cm but is still limited to the kidney.
T3a: Tumor has spread into the adrenal gland or into fatty tissue around the kidney, but not beyond a fibrous tissue called Gerota’s fascia, which surrounds the kidney and nearby fatty tissue.
T3b: Tumor has spread into the large vein leading out of the kidney (renal vein) and/or the part of the large vein leading into the heart (vena cava) that is within the abdomen.
T3c: Tumor has reached the part of the vena cava that is within the chest or invades the wall of the vena cava.
T4: Tumor has spread beyond Gerota’s fascia (fibrous tissue that surrounds the kidney and the fatty tissue next to the kidney).

Regional lymph nodes (N)

NX: Regional lymph nodes cannot be assessed (information not available).
N0: No regional lymph node metastasis.
N1: Metastasis to one regional (nearby) lymph node.
N2: Metastasis to more than one regional (nearby) lymph node. Distant metastasis (M):

Extent of Metastasis (M)

MX: Presence of distant metastasis cannot be assessed (information not available).
M0: No distant metastasis.
M1: Distant metastasis present; includes metastasis to non-regional (not near the kidney) lymph nodes and/or to other organs (such as the lungs, bones, or brain).

Renal Cell Cancer Stage Grouping

Once the T, N, and M categories have been determined, this information is combined in a process called stage grouping to determine a patient’s overall disease stage. This is expressed in Roman numerals from stage I (the least serious or earliest stage) to stage IV (the most serious or advanced stage).

Stage I: T1a-T1b, N0, M0. The tumor is 7 cm or smaller and limited to the kidney. There is no spread to lymph nodes or distant organs.

Stage II: T2, N0, M0. The tumor is larger than 7 cm but is still limited to the kidney. There is no spread to lymph nodes or distant organs.

Stage III: T1a-T3b, N1, M0 or T3a-T3c, N0, M0. Several combinations of T and N categories are included in this stage. These include any tumor that has spread to only one nearby lymph node but not to other organs. Stage III also includes tumors that have not spread to lymph nodes or distant organs but have spread to the adrenal glands, to fatty tissue around the kidney, and/or have grown into the large vein (vena cava) leading from the kidney to the heart.

Stage IV: T4, N0-N1, M0 or Any T, N2, M0 or Any T, Any N, M1. Several combinations of T, N, and M categories are included in this stage, which includes any cancers that have spread directly through the fatty tissue and beyond Gerota’s fascia, the fibrous tissue that surrounds the kidney. Stage IV also includes any cancer that has spread to more than one lymph node near the kidney, or to any lymph node distant from the kidney, or to any distant organs such as the lungs, bone, or brain.

Grading

The system for determining the characteristics of a cancer’s cells is called Fuhrman grading. The Fuhrman grade is determined by a pathologist, who will review the cellular details of your tumor. The grade is based on an examination of how closely the cancer cell’s nucleus (part of a cell in which DNA is stored) resembles a normal kidney cell’s nucleus.

Kidney cancers are usually given a Fuhrman grade on a scale of 1 through 4. Grade 1 kidney cancers have cell nuclei that look very much like a normal kidney cell nucleus. These cancers are usually slow growing and are slow to spread to other parts of the body (metastasize). They tend to have a good outlook (prognosis). Grade 4 kidney cancer, on the upper end of the Fuhrman scale, looks quite different from normal kidney cells and has a worse prognosis. Generally, the higher the Fuhrman grade the worse the prognosis.

Written by survivekidneycancer

July 14, 2010 at 7:21 PM

Posted in Kidney Cancer

Subtypes of Renal Cell Carcinoma (RCC)

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Not all kidney cancers are the same. There is an increasing understanding among clinicians and researchers that there are different subtypes of RCC and that they behave quite differently, both with regard to how aggressive they are in the patient and how they respond to treatment.  Ten or fifteen years ago, it was common for a pathology report from a patient with kidney cancer to read simply “Renal Cell Carcinoma.”  This simple diagnosis is now thought to be incomplete. Identification of the specific subtype or cell type (histology) of the kidney cancer can be as important in determining patient prognosis as knowing the stage or grade of the RCC. Your doctor should give you information regarding the histology, grade and stage of your kidney cancer. If not, you should feel comfortable asking for this information since it is an important part of your treatment planning.

The subtypes of RCC come from the description of the cell’s appearance and other characteristics. They include:

  • Clear Cell (conventional) RCC:  This is the most common form of kidney cancer and represents between 66% and 75% of all cases. Clear cell RCC is the cell type associated with the von Hippel Lindau (VHL) gene mutation in hereditary kidney cancer.  In fact, approximately 70% of non-hereditary cases of clear cell RCC also have aVHL mutation. Much of today’s research, which is attempting to identify new effective treatments for patients with locally advanced or metastatic disease, is focused on this disease subtype since it is the most common type of RCC.  When the tumor has not spread, prognosis is very good following surgical excision.  Prognosis for the patient is directly related to both the cancer’s stage (tumor size and rate of growth) and grade (the characteristics of a tumor’s cell structure). Staging and grading are both explained later in this chapter.  Patients with metastatic clear cell RCC – or a tumor that has spread to other parts of the body – have a significantly poorer prognosis.
  • Papillary RCC:  This is the second most common form of kidney cancer, making up approximately 15% of cases.  Papillary RCC itself is divided into two subtypes based on cell appearance: Type I (5%) and Type II (10%).  There is an increased incidence of papillary RCC in African Americans and an increased incidence of bilateral disease (involving both kidneys) associated with this subtype.  There are also hereditary forms of both Type I and Type II papillary RCC.  When papillary RCC has not spread, surgical removal is usually associated with an excellent prognosis.  However, when papillary RCC metastasizes to other locations in the body, most conventional therapies for RCC, such as immunotherapy are ineffective.
  • Chromophobe RCC:  This rare form of kidney cancer represents approximately 5% of RCC cases.  This type of RCC is thought to originate from the same cell type as those that form renal oncocytomas (see below). Hybrid tumors that contain features of both chromophobe RCC and renal oncocytoma have also been diagnosed.   There is a familial or inherited form of chromophobe RCC (in association with renal oncocytoma) called Birt Hogg Dubé syndrome, which is also associated with a specific genetic mutation. Chromophobe RCC rarely metastasizes until very late in its clinical course, and surgical removal of localized or even locally advanced disease is usually associated with an excellent prognosis.  Metastatic chromophobe RCC is quite rare, and no standard therapy currently exists.
  • Renal Oncocytoma:  This is a benign tumor of the kidney that makes up approximately 5% of all kidney tumors. These tumors do not metastasize, although they can grow to a large size in the kidney and invade local structures, which can result in symptoms requiring surgery.  They are thought to be related to chromophobe RCC, and it can be quite difficult to differentiate the two.  The tumor is treated by a partial or complete removal of the kidney.
  • Unclassified RCC: Less than 1% of renal cell carcinomas are an unclassified type and are very rare.  They don’t fit into one of the more common subtypes of RCC listed above.  When examined under a microscope, these unclassified cancer cells have a structure and genetic features that don’t match the description of the more common RCC subtypes.  This category usually includes aggressive tumors that do not respond to traditional therapy for RCC.
  • Collecting Duct Carcinoma:  This is a rare and very aggressive variant of kidney cancer that represents less than 1% of cases.  This form of RCC is usually metastatic at the time of diagnosis, and is more common in younger individuals.  Treatment has been directed at using chemotherapy-based regimens, similar to those used in the treatment of transitional cell carcinoma (see below), as these tumors do not respond to traditional RCC therapies such as bioimmunotherapy.
  • Medullary RCC:  This is also a very rare and aggressive variant of kidney cancer, thought to be a variant of collecting duct carcinoma.  It is commonly associated with the sickle cell trait, and therefore is more common in the African-American population.  It represents less than one percent of all kidney cancers diagnosed.  Chemotherapy remains the main focus of treatment for this disease.
  • Sarcomatoid RCC:  This condition, known as “differentiation,” can occur with any of the common RCC subtypes.  The term refers to the fact that the RCC cells — when viewed under the microscope — have the appearance of sarcoma cells.  The percentage of sarcomatoid differentiation is usually reflected in the tumor’s pathology report and relates to the tumor’s aggressiveness. The prognosis associated with Sarcomatoid RCC is usually poor. The condition is found frequently in patients whose kidney cancer has metastasized widely. This form of kidney cancer is sometimes treated with chemotherapy.
  • Transitional Cell Carcinoma of the Kidney:  Transitional cell carcinoma (TCC) of the kidney is a rare and potentially very aggressive tumor that should not be considered a true kidney cancer, but instead should be grouped with those cancers that develop from cells that line the urinary tract.  This includes TCC of the urinary bladder, which is far more common than TCC of the kidney. If the cancer has not spread, the tumor can be treated by surgical removal of both the kidney and its ureter, although recurrences of TCC in the bladder are common.  When the tumor is large or has metastasized, the prognosis is extremely poor, and treatment options are similar to those for metastatic urinary bladder cancer, which includes chemotherapy.

Written by survivekidneycancer

July 14, 2010 at 7:20 PM

Posted in Kidney Cancer

How to Learn More about Kidney Cancer

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Your Doctor

Your own doctor can be one of the best sources of information about your disease and its treatment. Doctors that specialize in treating cancer are known as oncologists. After an initial diagnosis is made, don’t be afraid to ask your oncologist many questions. You should also consider getting a second opinion from another doctor who is a kidney cancer specialist. If you do not know the name of a specialist, you may obtain names from the Kidney Cancer Association. Your doctor won’t be offended if you seek a second opinion. It is common practice. In fact, your doctor often gives second opinions to colleagues. You may not need to have tests repeated because often the results of your previous tests can be sent to the second doctor. Rarely will a second opinion change your diagnosis, but it can give you useful information and fresh insights about treatment alternatives. In addition, your insurance company may require a second opinion. If you are in a health maintenance organization (HMO), you should find out about its policy concerning second opinions. You’ll find more information about working with your doctor later.

The Kidney Cancer Association

The Kidney Cancer Association is available to assist you in many ways, including providing written information on the disease, treatment options, and resources. You can contact us by telephone to speak with a nurse who can help you. This website has valuable information that you can read, print, or share with family and friends.

Other Patients

Kidney cancer patients can learn a great deal from one another. The best way to do that is to attend a patient meeting sponsored by the Kidney Cancer Association or support groups sponsored by your local hospital. Support groups provide excellent open environments for frank exchange with other patients and professional counselors. Our message board and Facebook® Fan Page are good resources, too.

The National Cancer Information Service

No matter where you live in the United States, you can call 1-800-4-CANCER, the toll-free telephone number of the National Cancer Information Service. This information service is provided by the National Cancer Institute (NCI), which is part of the National Institutes of Health (NIH). The NIH is operated by the US Department of Health and Human Services. You can ask for a variety of free booklets.

Other Websites

There are many other websites that can help you understand the disease and its diagnosis, treatment options, dealing with the illness and side effects of treatment, work and coping with a life-threatening diagnosis. You must be careful because some medical information on the Internet is posted by nonprofessionals and is not reliable. Always check the site to learn more about the source of any information provided. Look for well-known, established sources online and don’t rely on any one website. Reputable sites with reliable information for patients are sometimes accredited (approved) by a governing body such as the “Health on the NET.” In any case, use common sense and compare sites carefully before considering online material.

Libraries

Once you have a basic understanding of your disease, you may want to go to the library and dig into medical books and journals. More and more research is being done as scientists and physicians gain new knowledge about how kidney cancer develops and spreads, in order to improve our ability to treat and cure more patients. Nursing literature may be helpful to understand the treatment options and management of side effects. The amount of research on kidney cancer being presented at national and international physician and nursing conferences and published literature reporting research results has increased significantly in the past five years. There are many meetings devoted to education and open dialogue and researchers are continually discovering new information about kidney cancer. Doctors and nurses will provide you with this information as they discuss treatment options appropriate for you, and care for you during the course of your treatments.

Genetic Causes of Kidney Cancer

Genetic factors have been linked to an increased risk of developing kidney cancer. A hereditary disorder called von Hippel-Lindau (VHL) disease is associated with a high risk of developing kidney cancer, for example. Scientists have isolated the gene responsible for VHL disease, and this discovery offers exciting future possibilities for improved diagnosis and treatment of some kidney cancers. Another genetic mutation is thought to be responsible for tuberous sclerosis, a disease characterized by small tumors of the blood vessels that results in numerous bumps on the skin, mental retardation, seizures, and cysts in the kidneys, liver, and pancreas. In some cases, tuberous sclerosis has been associated with renal cell carcinoma. Birt Hogg Dube Syndrome (BHD) is another disorder associated with kidney cancer that is characterized by the presence of multiple small bumps (nodules) on the skin covering the nose, cheeks, forehead, ears, and neck.  For more information about these genetic factors, as well as HLRCC and HPRCC, please click here.

External Factors

Some external factors, such as smoking and obesity, have been related to a higher incidence of kidney cancer. In an attempt to answer the question “Why me?” some people want to determine such factors as a cause for their cancer. Although it is important for people to know what factors or behaviors are associated with an increased risk of kidney cancer, blaming yourself for past behavior is neither helpful nor healing. The fact that a person’s behavior included a risk factor such as smoking doesn’t necessarily mean the factor caused the cancer.

Information and Fear

Some patients don’t think that actively seeking information about their disease will do any good. They think that whatever their doctor says is all they want or need to know. Others are afraid to learn more about kidney cancer. Information about survival statistics particularly frightens them. It is important, however, to remember that these statistics are based on population averages and are often several years old by the time they are published. Therefore, the most up-to-date information and factors that affect the risks and benefits of treatment may not be published. Your doctor and nurse will give this information to you. Asking questions is a very important way to reduce fear and anxiety and is the only way to truly empower yourself to make the best decisions for you and your family.

Some patients believe that information about kidney cancer is presented in complicated medical terms they won’t be able to understanding. But a great deal of information, including the resources recommended in this booklet, is specifically written for patients in easy-to-read language that requires no specialized training to understand. Your doctors and nurses will be very willing to answer your questions, because the more you understand the better you will be able to participate as an active member of your health-care team.

We think that learning more about the disease and your treatment choices will help you. History has shown that assertive patients who actively work to overcome cancer often increase the odds of survival, live longer, and enjoy life more. You can be a passive victim or an active fighter. The choice is yours. Our recommendation is to fight.

Don’t surrender!

A comprehensive look at types, symptoms, treatments and much more.  Use this page to formulate questions for your physician about the status of your kidney cancer.

According to the American Cancer Society (ACS), well over one million new cases of cancer are diagnosed each year in the United States. In recent years, the percentage of cases involving kidney cancer have made up only about 3% of the total (in 2005 more than 36,000 new kidney cancer cases were diagnosed.)

Kidney cancer occurs roughly twice as often in males as in females. 12,660 people died from this disease in 2005. However, more than 100,000 kidney cancer survivors are living in the United States right now, according to ACS. These statistics include both adults and children and include all forms of kidney cancer.

Renal cell carcinoma (RCC) is the most common type of kidney cancer. In terms of all cancers, renal cell carcinoma is relatively rare, representing about 3% of all adult cancers.  It is usually treated initially with surgery to remove the tumor.  If caught in early stages, the chance that it will return is low.  Unfortunately, it has few symptoms in its early stages so it is usually undiagnosed or misdiagnosed and not detected until the tumor has grown fairly large. At that point, it displaces other nearby organs, causing symptoms. Many kidney (renal) tumors are found incidentally on x-rays or ultrasound examinations performed for reasons that don’t relate to the tumor or any of its potential symptoms.

Thirty percent of kidney cancer patients show signs of advanced RCC when diagnosed. Fifteen to 25 percent of patients have metastatic disease at the time of their diagnosis, meaning their cancer has spread to other areas of the body.

The most common symptom of kidney cancer is painless urination of blood, a condition known as hematuria. This symptom occurs in 40% to 50% of patients. Often, blood in the urine will occur one day and not the next. (Note that blood in the urine can indicate other diseases besides kidney cancer, such as kidney stones. When blood in the urine does occur, a doctor should evaluate this symptom immediately.)

Other common symptoms of kidney cancer include the presence of an abdominal mass, a hard lump or a thickening or bulging under the skin that can be seen or felt as the tumor grows. There also may be back or flank pain or pressure. Kidney cancer occurs most often in men between the age of 40 and 60. Since back pain is common among people over 40 years of age, such pain is often ignored and the presence of kidney cancer can go undetected.

If the tumor has spread to distant organs, symptoms may vary, depending on the specific organ affected, though patients may notice unexplained weight loss, fevers, anemia, or high blood pressure. The following list includes symptoms patients describe at the time of their diagnosis. This demonstrates how common some symptoms are, and how infrequent others are.

Written by survivekidneycancer

July 14, 2010 at 7:19 PM

Posted in Kidney Cancer