The American Cancer Society’s most recent estimates for kidney cancer in the United States for 2023 are: About 81,800 new cases of kidney cancer (52,360 in men and 29,440 in women) will be diagnosed. About 14,890 people (9,920 men and 4,970 women) will die from this disease.
The cause of renal cell carcinoma remains unclear. However, there are certain risk factors that are linked to kidney cancer.
- Hereditary Kidney Cancer (Von Hippel Lindau)
- Polycystic Kidney Disease
- Renal Failure
- High Fat diet
Despite the above mentioned risk factors, the vast majority of cases of kidney cancer are seen in patients with no clearly identifiable risk factor.
Imaging remains the mainstay of diagnosis for renal cell cancers. The majority of renal tumors are diagnosed as an incidental finding (“incidentaloma”) during imaging evaluations for other symptoms or problems. The most common imaging modalities utilized to diagnose a renal mass suspicious for cancer includes an abdominal ultrasound, abdominal CT Scan or Abdominal MRI.
Based on these imaging studies, distinct features are used to assess the likelihood of a kidney mass as being cancerous. Although there are situations that do mandate a renal biopsy, kidney cancers are generally best diagnosed based on either one or several imaging modalities performed during the same time frame or over a strict period of monitoring (serial imaging).
CANCER GRADING AND STAGING
As previously mentioned, the determination of kidney cancer is most commonly made only after removal of the renal mass. A pathologist evaluates under a microscope not only the presence of cancer, but also the grade and stage of the cancer. In addition, further classification of the tumor, called histologic sub-typing, can as well be performed. Based on this information, a standardized classification system developed by the American Joint Committee on Cancer (AJCC) called the TNM Classification System is used to not only accurately stage a cancer, but also to determine whether any additional treatment is necessary.
Surgical removal remains the mainstay of therapy in most cases. In certain incidences, a period of observation coupled with very close patient follow-up is reasonable for small renal masses, as well as those masses suspected to have a low likelihood of being cancerous. In addition, some patients with advanced cancers, patients who are poor surgical candidates as well as patients refusing surgery are offered alternative treatment options including immune therapy, chemotherapy or radiation. Nevertheless, the surgical treatment for renal masses has undergone an enormous evolution over a short period of time.
OPEN VERSUS LAPAROSCOPIC NEPHRECTOMY
Open surgery (open radical nephrectomy) has been the standard treatment for renal masses up until the past decade. An 8 to 15 inch abdominal or flank incision is made to expose the kidney. Once the incision is made, the kidney is then systematically dissected and removed.
Due to advances in surgical technique and exposure to newer technologies such as laparoscopy, this same operation can instead be performed with “keyhole-sized” incisions. Carbon dioxide gas is used to inflate the abdominal cavity which then provides for a similar view of the kidney. The operation then proceeds in a similar fashion as the open surgery with the use of specialized laparoscopic instruments.
This “minimally-invasive” approach, called a laparoscopic radical nephrectomy, has rapidly evolved into a standard therapy due to comparable cancer control and recurrence rates as well as the dramatic benefits of less blood loss, less post-surgical pain, less need for narcotic pain medications, and a more rapid recovery with a laparoscopic approach.
RADICAL VERSUS PARTIAL NEPHRECTOMY
Radical nephrectomy, or complete removal of the kidney along with its surrounding fat, has been the standard treatment for renal masses up until the past decade. Surgical removal of just the renal mass, or partial nephrectomy, has become an acceptable treatment option in a highly select group of patients. This type of treatment is commonly referred to as “nephron-sparing” or kidney-sparing surgery and is recommended for patients at risk of dialysis with complete kidney removal, patient with medical problems that lead to kidney failure, and those patients with a single (solitary) kidney. As expertise in this complex procedure has evolved, partial nephrectomy is now being offered even on a more elective basis to preserve as much kidney function as possible. This procedure can be performed either as an open or laparoscopic procedure. The benefits of a laparoscopic partial nephrectomy are similar to those of a laparoscopic radical nephrectomy.
TUMOR EXTIRPATION VERSUS ABLATION
Tumor extirpation, or complete surgical removal of a cancerous mass, has been a standard practice in the treatment of kidney cancers. Only recently has this approach been challenged.
Tumor ablation refers to the destruction of a tumor without cutting or removing it. Tumor ablation remains arguably one of the most controversial areas in urology. Examples of ablative technologies include cryotherapy (freezing), radiofrequency ablation (heating), high-intensity focused ultrasound (heating), microwave thermotherapy (heating) and laser coagulation (heating).
All of these approaches incorporate energy either in the form of heat or cold to create a lethal environment in the area of the mass which then causes tumor death. All of these approaches are performed in a minimally-invasive and nephron-sparing fashion and therefore provides all of the previously mentioned benefits. Studies evaluating tumor ablation have all involved small groups of patients. Additionally, follow-up have been very short. Outcomes have been very hopeful. Certainly, in a highly select group of patients with appropriate parameters these technologies can be very effective in treating renal masses.
The Urology Center offers a full spectrum of approaches in the treatment of kidney tumors including all of the previously mentioned minimally-invasive approaches. Although the benefits laparoscopic, “nephron-sparing” and ablative surgical approaches are reviewed here, ultimately, the best treatment option is individual to each patient. We invite our patients to inquire further about these various treatment options.