INTRODUCTION

The kidneys are bean-shaped, approximately fist-sized organs that are located on each side the mid-back, just below the rib cage (figure 1). The kidneys filter the blood and get rid of excess water and waste in the urine.

The most common form of kidney cancer in adults is renal cell carcinoma. Renal cell carcinoma usually does not cause obvious symptoms, especially in the early stages. As a result, the cancer may not be discovered until it is advanced.

Treatment of renal cell carcinoma may include surgery to remove part or all of the kidney. In some people, a medicine is used to slow the growth of the cancer.

This article discusses the symptoms, diagnosis, and treatment options for renal cell carcinoma. More detailed information about renal cell carcinoma is available by subscription. (See "Prognostic factors in patients with renal cell carcinoma".)

RENAL CELL CARCINOMA SYMPTOMS

Most people with renal cell carcinoma (RCC) do not have obvious symptoms. This means that RCC is sometimes not found until the cancer is advanced. Of those with symptoms, the most common symptoms include:

• Blood in the urine (hematuria)
• Pain in the sides of the mid back (the flank)
• A lump in the abdomen or side of the back
• Weight loss
• Pain in the back, side, or stomach

If you have any of these symptoms, talk to your doctor or nurse.

RENAL CELL CARCINOMA DIAGNOSIS

If you have symptoms of renal cell carcinoma, your doctor or nurse may order a test, such as an ultrasound or CT scan, to look at the kidneys. In many cases, however, the cancer is found when one of these tests is done for another reason, and incidentally identifies an abnormal mass or growth in the kidney.

If you have an ultrasound that shows a growth on your kidney, a CT scan will be done. The CT scan may also tell if the growth appears cancerous and/or has spread outside the kidney (called metastasis).

Unlike other cancers, a biopsy is not always needed to be sure that you have renal cell carcinoma. Instead, the diagnosis may be based upon how the tumor looks on the CT scan. Later, the diagnosis is confirmed when the tumor or kidney is removed during surgery.

Staging — Once renal cell carcinoma cancer is diagnosed, the next step is to determine its stage. Staging is a system used to describe the size, aggressiveness, and spread of a cancer. A cancer's stage helps to guide treatment and can help predict the long-term outlook.

A renal cell carcinoma's stage is based upon:

• The size of the tumor
• Spread of the cancer to the nearby lymph nodes
• If there are signs of cancer in other organs (liver, lung, bone)

Renal cell carcinoma stages range from stage I (the tumor is smaller than 7 cm (about 3 inches) and has not spread outside the kidney) to stage IV (the tumor has spread to the outer layers of the kidney or has spread to distant lymph node(s) or other organ(s)).

In general, lower stage cancers are less aggressive or advanced and less likely to come back after treatment compared to higher stage cancers. Stage I, II, and III renal cell carcinoma (RCC) are referred to as localized RCC while stage IV is referred to as advanced or metastatic RCC.

LOCALIZED RENAL CELL CARCINOMA TREATMENT

The preferred treatment for most people with localized renal cell carcinoma is surgery to remove part or all of the kidney and if necessary, the regional lymph nodes. (See "Surgical management of localized renal cell carcinoma".)

The decision to remove part or all of the kidney depends upon your cancer's size, where it is located in your kidney, whether there are one or multiple tumors, and how well your kidneys work.

• If you have multiple tumors or your tumor is large or located centrally within the kidney, complete removal of the kidney may be necessary, especially if your other kidney works normally (see 'Radical nephrectomy' below)
• In other situations, or if your kidneys do not work well, removing part of the kidney may be a better option (see 'Nephron-sparing treatments' below)

Radical nephrectomy — Radical nephrectomy is the medical term for a surgery that removes the entire kidney and surrounding tissues. Most people can live with only one kidney.

Nephron-sparing treatments — Nephron-sparing treatments are treatments for renal cell carcinoma that do not remove the entire kidney. Normally, the kidneys filter waste out of the blood with tiny structures, known as nephrons. Nephron-sparing treatments allow some of the nephrons to continue working. This treatment is generally preferred if it is feasible and especially if your kidneys do not work well.

Nephron-sparing treatments include:

• Surgery to remove part of the kidney (called partial nephrectomy); this is the more common treatment
• A treatment that destroys the cancer by burning it (called radiofrequency ablation) or freezing it (called cryoablation)

Treatment after surgery — For people with localized renal cell carcinoma, further treatment is not usually needed after surgery. Further treatment has not been proven to decrease the chance of the cancer returning.

However, it is important to see your doctor on a regular basis after being treated for cancer to monitor for signs that the cancer has returned. (See 'Follow up after local treatment' below.)

TREATMENT OF ADVANCED RCC

For people with advanced or metastatic renal cell carcinoma, treatment with a medicine (called medical treatment) may be recommended instead of or along with surgery. Medical treatment may also be recommended if your cancer recurs after surgery.

Surgery to remove the kidney or areas outside the kidney where the cancer has spread (metastases) may be done before medical treatment. In people with advanced RCC, surgery does not usually cure the cancer, but it may allow you to have fewer symptoms or delay systemic medical treatment.

The three most commonly used medical treatments for advanced RCC are:

• Interleukin-2 (IL-2, an immune therapy)
• Anti-angiogenic therapies, a class of medicines that reduce the blood supply to the tumor, slowing or stopping growth of the tumor
• Targeted therapies, a class of medicines that slow the growth of the cancer

Advanced RCC is hard to cure. When possible, people with advanced RCC are encouraged to enroll in a clinical trial (see 'Clinical trials' below).

Interleukin-2 — Interleukin-2 is a treatment that works by triggering your immune system to attack the cancer cells. The treatment is given by IV over 5 days while you are in the hospital. The treatment is repeated in 15 days, and may be repeated again 12 to 14 weeks after the first dose. IL-2 therapy can produce long term cancer control in 5 to 10 percent of patients. (See "Immunotherapy of renal cell carcinoma".)

Treatment with IL-2 can cause severe and even life-threatening side effects. Side effects can include low blood pressure, fever, kidney failure, and an irregular heart rhythm. As a result, IL-2 is only recommended if you are healthy enough to tolerate the side effects.

Anti-angiogenic therapies — These therapies target the vascular endothelial growth factor (VEGF) pathway, a key pathway stimulating the growth of blood vessels. The tumor requires blood vessels to grow and survive. Kidney tumors depend on these blood vessels, and treatment with anti-angiogenic (anti-VEGF) therapies may slow or stop the tumor from growing for long periods of time.

Targeted therapies — Targeted therapies are medicines designed to slow the growth of tumor cells. The medicines are called "targeted" because they work by interfering with a step in the cancer's growth process. Targeted therapies cannot cure the cancer, but they may allow you to live longer and have fewer symptoms. (See "Anti-angiogenic and molecularly targeted therapy for advanced renal cell carcinoma".)

Anti-angiogenic and targeted therapies are an option for people with advanced or metastatic RCC, either as an alternative to or after failing IL-2 therapy.

The most commonly used anti-angiogenic therapies for renal cell carcinoma include:

• Sunitinib (Sutent)
• Sorafenib (Nexavar)
• Pazopanib (Votrient)
• Bevacizumab (Avastin)

While targeted therapies include:

• Temsirolimus (Torisel)
• Everolimus (Afinitor)

Some of these medications are available as a pill that you take by mouth while others are given into an IV. These medicines are given one at a time rather than in combination. The most common side effects include rashes, being tired, and high blood pressure.

FOLLOW UP AFTER LOCAL TREATMENT

Close follow up after local treatment (radical nephrectomy or nephron sparing treatment) is important for anyone with renal cell carcinoma. Follow up visits allow your doctor to look for signs that the cancer has returned.

During a follow up visit, you will have an exam, lab tests, and x-ray tests. Depending upon the stage of your cancer, these tests are recommended every 6 to 12 months for at least five years.

CLINICAL TRIALS

Progress in treating renal cell carcinoma requires that better treatments be identified through clinical trials, which are conducted all over the world. A clinical trial is a carefully controlled way to study new treatments or new treatment combinations. Ask for more information about clinical trials, or read about clinical trials at:

www.cancer.gov/clinicaltrials/learningabout

http://clinicaltrials.gov/

WHERE TO GET MORE INFORMATION

Your healthcare provider is the best source of information for questions and concerns related to your medical problem.

This article will be updated as needed on our web site (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for healthcare professionals, are also available. Some of the most relevant are listed below.

Patient level information — UpToDate offers two types of patient education materials.

The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.

Patient information: Kidney cancer (The Basics)

Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.

This topic currently has no corresponding Beyond the Basics content.

Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.

Clinical manifestations, evaluation, and staging of renal cell carcinoma
Epidemiology, pathology, and pathogenesis of renal cell carcinoma
Diagnostic approach, differential diagnosis, and treatment of a small renal mass
Immunotherapy of renal cell carcinoma
Anti-angiogenic and molecularly targeted therapy for advanced renal cell carcinoma
Prognostic factors in patients with renal cell carcinoma
Radiofrequency ablation and cryoablation for renal cell carcinoma
Role of surgery in patients with metastatic renal cell carcinoma
Surgical management of localized renal cell carcinoma
Surveillance for metastatic disease after nephrectomy for renal cell carcinoma

The following organizations also provide reliable health information.

• National Library of Medicine

     (www.nlm.nih.gov/medlineplus/ency/article/000516.htm)

• American Society of Clinical Oncology

     (www.cancer.net/patient/Cancer+Types/Kidney+Cancer)

• National Cancer Institute

     (www.nci.nih.gov/cancertopics/types/kidney)

• American Cancer Society

     (www.cancer.org/Cancer/KidneyCancer/OverviewGuide/kidney-cancer--adult--renal-cell-carcinoma-overview-what-is-kidney-cancer)

Patient Support — There are a number of online forums where patients can find information and support from other people with similar conditions.

• About.com Cancer Forum

     (http://cancer.about.com/forum)

[1-4]