Kidney Cancer (Renal Cell Carcinoma; RCC)

What is Kidney Cancer?

The kidneys are paired organs in the abdomen of the human body. They filter the blood to remove toxins, waste chemicals and water. This filtered fluid is then concentrated to form urine. From the kidneys, the urine passes out into the ureters (connecting pipes) to be stored in the bladder.

The kidneys also produce a hormone that stimulates the bone marrow to produce red blood cells. Other hormones are produced and act on the kidneys to regulate how much water is kept in the body and how much is passed out as urine.

For more information, see the Renal System.

Renal cell carcinoma (RCC) is the most common form of cancer that originates (starts to grow) in the kidney. Cancers that have started to grow in a particular location (i.e. they have not spread there from somewhere else) are known as primary cancers. Cancers that have spread from somewhere else are known as "secondary cancers" or "metastases". Secondary cancer in the kidney is more common than primary kidney cancer. "Renal" is a technical word referring to the kidney. Carcinomas are cancers that grow from cells that line body organs (epithelial cells).

RCC occurs due to mutations (abnormalities) of cells in the kidney's filtering system. RCCs make up 80-85% of primary kidney (renal) cancer. Other rarer types of kidney cancer include:

Transitional cell carcinomas, which are the next most common type (8%);
Collecting duct tumours;
Renal sarcomas;
Lymphomas;
Carcinoids;
Oncocytomas;
In children, nephroblastoma (Wilms' tumour) makes up 5-6% of primary renal kidney tumours; and
Renal medullary carcinoma is a rare complication of sickle cell disease.

Von-Hippel Lindau syndrome is a condition which causes RCC affecting both kidneys and causes tumours in other organs, because of an underlying genetic disorder.

Statistics on Kidney Cancer?

Worldwide, over 100,000 people die of RCC each year. Renal cell carcinoma is the seventh most common cancer and tenth most common cause of cancer-related deaths among men. Overall, approximately 2-3% of all cancers are renal cell carcinomas. Renal cell carcinomas make up 80 - 85% of all primary renal cancer in adults.

Males were previously thought to have been twice as likely to develop RCC as females,however this gap is narrowing.

The number of cases of RCC being diagnosed is increasing by approximately 2% per year. This may be because many RCCs are now diagnosed by coincidence when someone has scans (such as ultrasounds or CT scan) performed for other reasons. It is possible that because such scans are becoming more common, more RCC is being diagnosed, and at an earlier stage. The average size of RCCs at diagnosis is decreasing. The number of deaths due to RCC are also decreasing.

In Australia, there are just over 2,000 new cases of primary kidney cancer diagnosed each year. Australians have a 1 in 74 risk of developing RCC during their lifetime. Kidney cancer caused 855 deaths in Australia in 2007 (539 men, 316 women), accounting for 0.6% of all deaths.

Primary kidney cancer is mostly a disease seen in adults over 40. The average age of people found to have renal cell carcinoma is 55 years. The disease is rare in children.

Classification

Kidney cancer can be classified into several different types based on the appearance of the cancer cells under a microscope (this is called the microscopic appearance or microscopy), and other genetic factors. The main subtypes are:

Clear cell carcinoma (75-85%);
Papillary cell (chromophilic) carcinoma (10-15%);
Chromophobic carcinoma (5-10%);
Oncocytic (uncommon); and
Collecting duct (very rare).

Fewer than 3% of RCCs are unclassified, and these tumours are thought to have a worse prognosis.

Translocation carcinomas are a type of RCC that occur in children who have received chemotherapy for malignancy, bone marrow transplant preparation, or autoimmune disorders.

Knowing the type of renal cancer will help your doctors to make the most appropriate decision about treatment options.

Risk Factors for Kidney Cancer

Renal cell carcinoma RCC is linked to a number of risk factors. These include:

Cigarette smoking, which is the most important risk factor. It doubles the likelihood of developing RCC, and may be associated with up to one third of all cases;
Acquired cystic kidney disease: dialysis patients (who require a machine to filter their blood, because their kidneys do not work well enough) who develop polycystic disease of the kidneys appear to be most at risk for RCC. The estimated risk of RCC amongst this group is 30 times greater than the general population.Acquired cystic disease develops in approximately 35 to 50% of chronic dialysis patients. Around 6% of these eventually develop RCC, commonly with multiple tumours in both kidneys. Men (ratio 7:1) and people with large cysts in large kidneys appear to be at significantly increased risk of developing kidney cancer, which tends to occur after 8-10 years of dialysis;
Obesity, which is being very overweight, appears to be associated with an increased risk of developing RCC in both men and women;
High blood pressure,also known as hypertension, has been found to be a risk factor for RCC, independently to obesity and smoking;
Occupational exposures to toxic compounds: risk of RCC is increased in workers exposed to asbestos, cadmium, petroleum products, dry-cleaning solvents, as well as those who work in the iron and steel industries;
Genetic predisposition: several genetic syndromes have been associated with an increased risk of RCC. These include von-Hippel Lindau (VHL) syndrome, hereditary papillary renal cancer, hereditary leiomyoma RCC syndrome, and Birt-Hogg-Dube syndrome;
Unopposed oestrogen therapy: One study found that women who have more than 5 children are at increased risk of developing RCC. Use of the combined oral contraceptive pill was associated with a slightly reduced risk of RCC;
Analgesic abuse nephropathy: individuals who use aspirin or phenacetin contained within analgesics (painkillers) over a long period are at risk of developing chronic renal failure. In addition to kidney failure, they may also be at an increased risk of RCC;
Childhood chemotherapy: Chemotherapy given during childhood to treat cancer, autoimmune disorders, or for bone marrow transplantation has been associated with increased risk of RCC (translocation carcinoma as discussed above) because of genetic abnormalities caused by the treatment; and
Previous radiation therapy:Renal cell carcinoma caused by radiation occurs in less than 1% of cases of RCC, and in one study it occurred 25-35 years after radiation therapy.

Screening

Due to the fact that RCC is uncommon in the general population, screening of people who have no symptoms of RCC is not recommended. People at high risk for development of RCC may be monitored with abdominal ultrasound, CT, or MRI.

Those who may benefit from screening for RCC include:

Individuals with inherited conditions such as VHL syndrome or tuberous sclerosis;
Those with end stage renal disease who have been on long term dialysis;
Those with a strong family history of RCC; or
Individuals with a history of previous kidney radiation.

Progression of Kidney Cancer

Renal cell carcinomas often cause few symptoms, and so they may be diagnosed quite late. They also tend to spread to other organs quite early. About one quarter of RCCs will have spread to other organs by the time they are recognised and diagnosed. 40-50% of patients with RCC will eventually develop kidney cancer elsewhere (metastatic disease). RCCs tend to start as small tumours, which get larger, then grow into surrounding tissue, before spreading to nearby organs, then elsewhere.

The common sites for metastasis (spread) of RCC include:

Local lymph nodes;
Lungs (>50%);
Bones (>30%);
Liver;
Soft tissue;
The adrenal gland on the same side as the affected kidney;
The other kidney; and
Brain/central nervous system.

Staging

At the time as someone is diagnosed with kidney cancer, the specialist will determine the "stage" of their disease. There are four stages. Depending on the stage of the disease (i.e. how big the tumour is, or whether it has spread), the best decision about treatment and the likely outcomes can be discussed. The stages below are based on the Robson system, which is one of the methods for staging RCC that is used in Australia. The survival rates quoted are general guidelines only, and should be discussed further with your doctor.

Stage 1: the cancer is only within the kidney, and has not spread. This stage has the best long-term survival and is most likely to be cured with surgery. The five year survival rate is almost 90%.
Stage 2: the cancer has spread outside of the kidney to the surrounding fat, or to the adrenal gland, which sits on top of the kidney. This stage also has a high rate of survival and surgery is a good treatment option. The five year survival rate is more than 75%.
Stage 3: the cancer may be of any size, but it extends outside the capsule of the kidney and into blood vessels. In this stage, the specialist will give advice about appropriate treatment. There is a 5 year survival rate of close to 65%.
Stage 4: the cancer of the kidney may be of any size. However, in this stage the tumour has spread outside the kidney to other organs (in addition to, or other than the adrenal gland on the same side) and so has the lowest rate of long-term survival because. The 5 year survival rate is 10%.

The table below summarises the staging of RCC. The TNM column on the left is one method of staging RCC, while the Robson Stage on the right is another method that is used in Australia. The extent of disease column describes how large the RCC is, and how far it has spread at the time the person is diagnosed.

Staging at presentation

TNM Stage	Extent of disease	Robson Stage
T1	Tumour <2.5cm, confined to the kidney	I
T2	Tumour >2.5cm, confined to the kidney
T3a	Tumour spread to perinephric fat or adrenal	II
T3b	Tumour spread to renal vein	IIIA
T3c	Tumour spread to inferior vena cava
N1-3 M0	Tumour spread to local lymph nodes	IIIB
T3b N1-3	Tumour spread to local vessels and nodes	IIIC
T4a	Tumour spread to adjacent organs 9other than ipsilateral adrenal)	IVA
M1 N4	Distant metastases	IVB

Figure 1: Necrosis haemorrhage and tumour in the kidney.

Clinical Examination of Kidney Cancer

Classical symptoms

Renal cell carcinoma Kidney cancer is usually silent and may go unnoticed for several years. There are 3 classic things that may suggest kidney cancer to a doctor: back (loin) pain, a lump/mass in the flank of the back, and blood in the urine. Of these, blood in the urine is the most common finding. However, less than 1 in 10 people with kidney cancer will have these symptoms. This is why kidney cancer is often not picked up until the tumour is large.

Other symptoms which may occur in RCC include those associated with anaemia (30%) such as being pale and breathless on exercise, and high blood pressure (30%). Fever occurs in up to 20% of individuals, usually comes and goes, and is often associated with lack of appetite, weight loss, fatigue and night sweats.

Metastatic disease

25-30% of individuals will have advanced or metastatic disease on presentation. Advanced disease may present with symptoms such as: fever (20%), general feeling of being unwell known as malaise (30%), weakness and weight loss (30%).

Common sites of metastasis of RCC are:

The lungs, which may present as breathlessness or cough;
Bones, which may present as bone pain;
The liver, which may present as jaundice (yellow skin); or
The brain, which may present as seizures or stroke-like symptoms.

How is Kidney Cancer Diagnosed?

CT and Ultrasound

A scan of the abdomen is the first step in diagnosing kidney cancer. An abdominal CT, formerly known as a CAT scan, is the most commonly performed. An ultrasound is the alternative way to look at the kidneys, and this may also show a mass.

Figure 2: Tumour in the right kidney and a missing left kidney.

Blood tests

As a part of investigating possible kidney cancer, a number of blood tests may also be done. This includes checking for anaemia (a low level of red blood cells which carry oxygen around the body). Other blood tests can check liver markers, and will help doctors decide if the tumour has spread into the liver or the bones.

Tissue diagnosis: resection or biopsy

It is important to have a series of tests including the CT scan and blood tests in order to plan the best form of treatment. If the tests indicate someone may have kidney cancer, a sample of kidney tissue is needed. This sample will be examined under a microscope to decide whether it is cancerous or not.

Tissue samples may be obtained by passing a needle into the kidney, and removing some tissue for examination, which is known as a renal biopsy. More commonly, if scans and blood tests strongly indicate the mass may be cancer, the kidney, or part of the kidney will be removed (nephrectomy, partial nephrectomy), and the suspicious tissue is examined after removal. This avoids the need for two procedures, provides more accurate information, and avoids possible spread of cancer during the process of biopsy. Examination of the tissue after removal is important to provide information about the correct treatment and likely outcome of the cancer. If RCC has already spread, it may be easier to get a biopsy specimen from a site other than the kidney.

MRI

MRI may be used when results of CT and ultrasound scans are unsatisfactory or if CT can't be used (e.g. due to an allergy to the contrast agent).

Bone scans and PET

Bone scans may be performed if individuals with RCC have bone pain or abnormal liver function tests. PET may be more sensitive that bone scanning to detect spread of cancer to the bones, however it is more expensive and is not generally used for routine staging.

Prognosis of Kidney Cancer

Renal cell carcinoma Kidney cancer that is detected in its early stages has a high rate of cure. However, larger tumours have often already spread to the lungs, liver, bones or elsewhere. Once the tumour has spread, a person's length of survival is significantly decreased. In individuals whose cancer has not spread beyond the kidneys, 70% will be alive in 5 years (known as 5 year survival rate). Some people have their renal cancer detected before they have symptoms because of a coincidental finding on a CT scan or ultrasound. They have the best survival rates because their cancers are usually small.

The outcome of RCC depends on:

Staging of disease at presentation;
Histological grade of the tumour; and
Clinical factors.

Staging of disease at presentation

Staging of disease at presentation refers to the amount that the cancer has grown and spread by the time it is diagnosed. See staging above. Staging is the most important factor in deciding the likely outcome of the kidney cancer. The quoted survival rates below are guidelines only, and should be discussed further with your doctor.

Prognosis for RCC based on stage is as follows:

The overall (international) average five year survival rates for renal carcinoma are 45%;
Individuals with stage I (T1N0) have a five year survival rate over 90%, and those with stage II (T2N0) have a 75-95% 5 year survival rate;
Individuals with stage III (T3N0 or T3N1) who have their kidney removed have a five year survival rate of 59-70%;
The five year survival rate where cancer has spread to the lymph nodes is 25-35%; and
Less than 10% of individuals with distant metastases survive five years. Average survival for individuals with stage IV disease (T4, N2 or distant metastases) is 16-20 months.

Histological grade of the tumour

Histological grade refers to how aggressive the cancer looks based on viewing its cells under a microscope in a laboratory. There are 4 grades, with 1 having the best prognosis (five year survival 89%), and 4 being the worst (46% five year survival). Less important than the stage or grade of the tumour is the subtype, which was discussed in classification. Some subtypes however, such as sarcomatoid clear cell carcinoma, renal medullary carcinoma and collecting duct carcinoma are known to be more aggressive and tend to be associated with poorer prognosis (survival).

Clinical factors

As with all cancer, clinical factors such as a person's general health and fitness, or the severity of their symptoms, have a significant impact on their survival rates. Younger people (20-40 years) have a slightly better outcome despite having more symptoms at presentation, probably due to lower rates spread of cancer to their lymph nodes.

In Australia there has been an improvement in 5 year survival rates of RCC for both men and women. The 5-year survival rate for men with RCC has increased from 50.8% to 59.9% over this period, and from 49.4% to 57.5% in women. This is considerably higher than the quoted international figures.

How is Kidney Cancer Treated?

Renal cell carcinoma Treatment of RCC has improved considerably. Your doctors will discuss with you which of these options may be suitable depending on your specific type of cancer.

Some treatments have been shown to be more effective in research. However, your oncologist is the best person to ask about the effectiveness of treatment. It is important to be aware that all medications and treatments may have side effects.

Who is involved in the treatment team?

Oncologist: Specialist cancer doctor who coordinates the care for individuals with RCC. The oncologist will make decisions regarding immunotherapy, molecularly targeted therapy, and chemotherapy;
Surgeon: A general surgeon, possibly one who specialises in renal (kidney) surgery, will play a key role in the treatment of RCC if surgery is thought to be appropriate;
Renal physician: A specialist kidney doctor may become involved in treatment if overall kidney function is significantly damaged. This is particularly the case if the RCC involves both kidneys, or the function of the remaining kidney is poor.
Radiation oncologist: may be involved in individuals for whom radiotherapy is thought to be an appropriate treatment. Specialist technicians are involved to deliver the radiotherapy;
Palliative care specialists: Doctors and nurses who may become involved if the cancer is not curable. This team specialises in providing care that aims to treat symptoms and improve quality of life, rather than cure the disease itself.
Nurses: play a large role in providing care, support, and administering treatment, particularly while inpatient (hospital) care is required. Some nurses specialise in oncology (cancer), and are experts in managing side effects of therapy and the disease itself.
Allied health staff: depending on the needs of the individual patient, health care professionals such as dietitians, social workers, psychologists, physiotherapists and occupational therapists may contribute to the care of patients with RCC.

Surgery

Renal cell carcinoma Resection is the best treatment for RCC that has not spread (stage I, II and III disease), and will cure the majority of people whose cancer falls into this category. The extent of surgery depends on the size and location of the tumour.

Surgical options include removal of the whole kidney (radical nephrectomy) or renal (kidney) sparing approaches (partial nephrectomy), by either open or keyhole (laparoscopic) methods.

In stage I or II RCC the standard management is radical nephrectomy. In individuals who have only one kidney, or who have small tumours, only part of the kidney (partial nephrectomy) may be performed depending on the size and location of the cancer. RCC in both kidneys occurs more commonly in people who have inherited conditions such as von Hippel-Lindau disease, tuberous sclerosis and papillary RCC. Surgery in this instance aims to spare as much kidney tissue as possible, followed by close monitoring for development of further RCCs. Rarely, radical nephrectomy in addition to surgery to remove metastases may be considered in selected people who have a removable primary tumour in the kidney, in addition to a single metastasis elsewhere. Close monitoring following surgical removal is important to allow early diagnosis if the cancer returns.

For some people, surgery may not be appropriate, such as those who cannot tolerate anaesthetic, the very elderly, and those with other severe medical conditions. Most small tumours (previously all thought to be benign) grow slowly, cause no symptoms, and don't spread. Around 40% of tumours smaller than 1cm are found to be benign.For this reason, conservative management (i.e. no surgery) with regular monitoring ("watchful waiting") may be the most appropriate treatment option for these patients.

For people with advanced or metastatic disease (that has spread beyond the kidney), curative surgery is usually not possible. In these cases a number of different therapies have been trialled. Recent studies have improved the understanding of how RCC occurs, and have led to development of specific treatments that are targeted to treat the disease process. These specific treatments have shown selective benefit in previously untreatable metastatic kidney cancer.

For more information, see Nephrectomy.

Non-surgical treatments

Immunotherapy

Renal cell carcinoma A medication called Interleukin-2 (IL-2) given at high doses can sometimes be an effective treatment for RCC by activating the body's immune system to fight the RCC. Suppression of the cancer may last years, and those who respond completely (approximately 10% of people) tend to remain well long term. However, IL-2 has significant side effects.

Immunotherapy for individuals whose cancer has returned following surgery is most effective for those who have a high level of function (good performance status). People with a good performance status are able to move around and carry out fairly normal daily activities. People with poor performance status are confined to bed or a chair for most of the day. Immunotherapy was previously very widely used to treat RCC. Now, it is mainly used to treat people who have a good performance status, and have other factors that indicate their cancer will respond well to treatment.

Other forms of immunotherapy (e.g. IFNa, low dose IL-2) have been replaced by molecularly targeted agents (below).

Those with non-clear cell RCC do not appear to respond to immunotherapy, though research related to this is limited.

Molecular targeted therapies

Development of agents which target the specific biological pathways that cause RCC has been the main development in the treatment of RCC in recent years.

VEGF (vascular endothelial growth factor) receptor inhibitor sunitinib (Sutent), works by blocking the pathway that allows blood vessels to supply the cancer as it is growing. It is an effective first line (initial) therapy for advanced clear cell carcinoma, which is the most common type of RCC.

Sorafenib (Nexavar) and bevacizumab (Avastin) are other similar forms of therapy that may be used as initial treatment in people with advanced RCC, or those who have failed cytokine therapy.

Temsirolimus (Torisel) is another drug which works on a different pathway, and may be used as initial treatment for people with advanced RCC.It significantly increases survival and is a good alternative to VEGF pathway inhibition, particularly in people with a poor prognosis.

It is unclear whether these therapies are effective in treating non-clear cell RCC.

Cytoreductive (debulking) nephrectomy

Cytoreductive nephrectomy involves removal of most of the primary tumour from the kidney. People with advanced RCC who undergo cytoreductive nephrectomy before treatment with IFNa immunotherapy have improved survival compared with those whose primary kidney tumours are not removed.

Pre-operative biopsy may be used in individuals being considered for cytoreductive nephrectomy, in order to confirm that the tumour is clear cell carcinoma (the only subtype for which IFNa has been proven to work).

The role of cytoreductive nephrectomy in people who will receive molecularly targeted therapy remains unclear. The role of surgery with IFNa therapy may change in the future as molecularly targeted therapies improve.

Chemotherapy

Clear cell carcinomas do not respond to traditional chemotherapy.

Some non-clear cell carcinomas may respond to chemotherapy in a minority of cases. Combinations of platinum agents, ifosfamid, gemcitabine, and taxanes tend to be used. They may be effective for treating collecting duct tumours, sarcomatoid RCCs and renal medullary carcinoma (which may also respond to bortezomib).

People with papillary (chromophilic) RCC do not tend to respond to chemotherapy.

Chemotherapy or molecularly targeted agents are the preferred first treatment for individuals with advanced RCC found to be non-clear cell carcinoma.

Hormone therapy

Progesterone therapy has been used in the past to treat RCC that has spread. There is no evidence for this practice, despite extensive studies. RCCs are not hormone dependant or hormone responsive. However, some people find hormone therapy is effective in reducing symptoms of anorexia (loss of appetite).

Other hormonal agents such as anti-oestrogens, androgens, and combinations with other therapies have not been proven effective.

Radiation therapy

Most renal cell carcinomas are radiation resistant. However, radiation therapy may be useful for painful bony metastases, brain metastases and painful recurrences of tumour in the renal bed (where the kidney usually sits).

Radiotherapy has also been used following nephrectomy for individuals whose disease is highly likely to recur locally, though this has not been proven to be effective.

More information

For more information on kidney anatomy, cancer, animations and treatment, see Kidney Cancer.

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