Kidney (renal) cancer: from a mass on imaging to a treatment plan

Signs and risk factors

Possible signs include blood in the urine, persistent pain below the ribs, a lump in the lower or side back, unexplained weight loss, fatigue, loss of appetite, a fever that comes and goes without infection, anemia, leg or ankle swelling and high blood pressure. Risk factors include smoking, excess body weight, high blood pressure, a family history of kidney cancer, certain inherited conditions such as von Hippel-Lindau disease, long-term heavy use of some pain medicines, and long-term workplace exposure to chemicals such as asbestos or cadmium. Men are more likely than women to develop it, and risk rises with age. Having a risk factor does not mean you will get kidney cancer.

A kidney mass was found: what happens next

Kidney tumors are often discovered on imaging done for another reason. A mass needs to be characterized: not every kidney mass is cancer, and not every cancer needs the same response. Common tests:

• Imaging: ultrasound, CT, MRI (useful if you cannot have CT contrast dye) and sometimes an intravenous pyelogram. Advanced Urology also offers PET/CT, which can help stage kidney cancer and look for spread or recurrence in selected patients.
• Blood tests: a blood count (anemia can be a clue) and chemistry tests of kidney function.
• Urine tests: urinalysis, and sometimes cytology to look for abnormal cells.
• Biopsy: a thin needle sample can confirm cancer and its type, but is not always needed if imaging already provides enough information.

Renal cell cancer is the most common type of kidney cancer in adults. Cancers that begin in the renal pelvis or ureter are a different disease with different treatment.

Understanding stage

Staging describes the extent of cancer in the body and usually follows the TNM system, which your pathology report may reference. This is a patient-level summary, not a substitute for your own report:

• Stage I: tumor 7 centimeters or smaller, found in the kidney only.
• Stage II: tumor larger than 7 centimeters, found in the kidney only.
• Stage III: one of these: the cancer, of any size, has spread to nearby lymph nodes; or it has spread to blood vessels in or near the kidney (the renal vein or vena cava), to the structures in the kidney that collect urine, or to the layer of fatty tissue around the kidney, and may have spread to nearby lymph nodes.
• Stage IV: one of these: the cancer has spread beyond the layer of fatty tissue around the kidney and may have spread into the adrenal gland above the kidney or to nearby lymph nodes; or it has spread to other parts of the body such as the lungs, liver, bones, brain, adrenal glands or distant lymph nodes.

Stage, together with your age and general health, affects prognosis and treatment options. Renal cell cancer can come back many years after treatment, so follow-up matters.

Treatment options and trade-offs

• Surgery. Removing part or all of the kidney (nephrectomy) is the main treatment for many kidney cancers. A partial nephrectomy removes the cancer and some tissue around it and leaves the rest of the kidney; a radical nephrectomy removes the kidney and surrounding tissue; a simple nephrectomy removes the kidney only. Whether the kidney can be spared depends on the tumor and your situation.
• Ablation. Cryotherapy (freezing) or thermal ablation (heat) to destroy abnormal tissue, in selected situations.
• Targeted therapy, immunotherapy and radiation therapy. Treatment types used depending on stage, the type of cancer and your oncology team. Targeted therapy blocks cancer growth, immunotherapy boosts the immune response, and radiation uses high-energy x-rays.

Dr. Mally is trained in da Vinci robot-assisted surgery, including robotic partial nephrectomy and nephrectomy. Whether a robotic approach suits a given tumor depends on its size, location and your health. As with any operation, surgical and anesthesia risks apply. Ask how each option could affect your kidney function over the long term.

Questions to bring, including for a second opinion

A second opinion can confirm a diagnosis and plan; the second doctor will want your pathology report and scans. Helpful questions: Is this mass cancer, and how sure are we? What stage is it? Can the kidney be spared? What are the risks to my other kidney and my kidney function? What follow-up scans will I need? Who is on my care team?

Ask the office how to arrange a review of your imaging and records.