Patient education: Renal cell carcinoma (kidney cancer) (Beyond the Basics)
- Michael B Atkins, MD
Michael B Atkins, MD
- Section Editor — Malignant Melanoma and Other Cutaneous Neoplasms; Cancer of the Kidney
- Deputy Director
- Georgetown Lombardi Comprehensive Cancer Center
- Jerome P Richie, MD, FACS
Jerome P Richie, MD, FACS
- Section Editor — Cancer of the Urethra, Penis, and Ureter; Urologic Surgery; Prostate Cancer
- Elliott Carr Cutler Professor of Surgery
- Harvard Medical School
The kidneys are bean-shaped, approximately fist-sized organs that are located on each side of 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 a 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".)
More detailed information about renal cell carcinoma, written for healthcare providers, is also available by subscription. (See 'Professional level information' below.)
RENAL CELL CARCINOMA SYMPTOMS
Most people with renal cell carcinoma do not have obvious symptoms. This means that renal cell carcinoma is sometimes not found until the cancer is advanced. When symptoms do occur, the most common ones include:
●Blood in the urine (hematuria)
●Pain in the sides of the mid back (the flank)
●A palpable mass in the abdomen or side of the back
●Swelling around the left testicle
●Weight loss, night sweats, and/or unexplained fever
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 (RCC), your doctor or nurse may order an imaging test, such as an ultrasound or computed tomography (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, generally before and after intravenous contrast injection, will be done. The CT scan may also tell if the growth appears cancerous and/or has spread outside the kidney (metastasized).
Unlike other cancers, a biopsy is not always needed to be sure that you have RCC. Instead, the diagnosis may be based upon how the tumor looks on the CT scan. Later, the diagnosis is confirmed when the tumor or entire kidney is removed during surgery.
Staging — Once RCC 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.
An RCC's stage is based upon:
●The size of the tumor
●Spread of the cancer to the nearby lymph nodes
●Signs of cancer in other organs (liver, lung, bone, etc)
RCC stages range from stage I, meaning the tumor is smaller than 7 cm (approximately 3 inches) and has not spread outside the kidney, to stage IV, meaning the tumor has spread beyond the outer layers of the kidney or 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 with higher stage cancers. Stage I, II, and III RCCs are referred to as localized RCCs, while stage IV is referred to as an advanced or metastatic RCC.
LOCALIZED RENAL CELL CARCINOMA TREATMENT
The preferred treatment for most people with localized renal cell carcinoma (RCC) is surgery to remove part or all of the kidney and, if necessary, the nearby lymph nodes.
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 RCC 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 in the same kidney to continue working. This treatment is generally preferred if it is feasible, especially if your kidneys do not work well, a situation in which preserving as many nephrons as possible is a priority.
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 RCC, further treatment is not usually provided 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 RENAL CELL CARCINOMA
For people with advanced or metastatic renal cell carcinoma (RCC), 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. For someone with advanced RCC, surgery does not usually cure the cancer, but it can reduce symptoms or delay systemic medical treatment.
The most commonly used medical treatments for advanced RCC are:
●Immune therapy (also called immunotherapy) – This is the name for drugs that work with your immune system to stop or slow the growth of cancer cells, including interleukin-2 (IL-2) and nivolumab.
●Targeted therapy – this includes anti-angiogenic therapies, a class of medicines that reduce the blood supply to the tumor, thus slowing or stopping growth of the tumor, as well as other medicines that directly inhibit 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, as optimal use of approved treatments and several promising not-yet-approved agents are still being investigated. (See 'Clinical trials' below.)
Interleukin-2 — IL-2 is a treatment that works by triggering your immune system to attack the cancer cells. The treatment is given intravenously (by IV) over five days while you are in the hospital. The treatment is typically repeated in 15 to 22 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.
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 and are being treated in a facility with experience in its administration.
Nivolumab — Nivolumab (brand name: Opdivo) is a type of drug called an "anti-PD-1 checkpoint inhibitor" that unleashes the body's immune system so it can reject the kidney cancer. Nivolumab is given once every two weeks (by IV) as an outpatient and is continued unless there is evidence of disease progression, complete disappearance of disease, or severe side effects. Treatment with nivolumab may decrease the extent of your kidney cancer and help you live longer. Nivolumab can cause the body to develop an immune reaction against its own tissues. This can result in a wide range of side effects, which can be severe or life-threatening.
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. These therapies are an option for people with advanced or metastatic RCC, either as an alternative to or after immunotherapy. (See "Anti-angiogenic and molecularly targeted therapy for advanced or metastatic clear-cell renal cell carcinoma".)
One set of these agents targets the vascular endothelial growth factor (VEGF) pathway, which partly controls the growth of blood vessels. The blood vessels feeding RCC tumors are particularly dependent on VEGF, so treatment with anti-VEGF therapies can damage tumor blood vessels, and this may slow or stop the tumor from growing for long periods of time. Drugs in this category include:
●Pazopanib (brand name: Votrient)
●Sunitinib (brand name: Sutent)
●Cabozantinib (brand name: Cabometyx)
●Axitinib (brand name: Inlyta)
●Sorafenib (brand name: Nexavar)
●Bevacizumab (brand name: Avastin)
●Lenvatinib (brand name: Lenvima)
A second target for treatment of RCC involves blocking a specific protein called the mechanistic (or mammalian) target of rapamycin (mTOR). These include:
●Temsirolimus (brand name: Torisel)
●Everolimus (brand name: Afinitor)
Some of these medicines are available as a pill that you take by mouth, while others are given into an IV. These medicines are typically given one at a time rather than in combination. Recently, the combination of lenvatinib and everolimus has been approved, and it may be offered to some patients if initial treatment approaches fail. The most common side effects of mTOR inhibitors include rashes and fatigue, and for VEGF-targeted therapy, they include fatigue 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 or computed tomography (CT) scans. Depending upon the stage of your cancer, these tests are recommended every 6 to 12 months for at least five years.
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:
Videos addressing common questions about clinical trials are available from the American Society of Clinical Oncology (http://www.cancer.net/pre-act).
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.
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.
Overview of the treatment of renal cell carcinoma
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 or metastatic clear-cell 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
Definitive surgical management of renal cell carcinoma
Surveillance for metastatic disease after definitive treatment for renal cell carcinoma
The following organizations also provide reliable health information.
●National Library of Medicine
●American Society of Clinical Oncology
●National Cancer Institute
●American Cancer Society
- Klapper JA, Downey SG, Smith FO, et al. High-dose interleukin-2 for the treatment of metastatic renal cell carcinoma : a retrospective analysis of response and survival in patients treated in the surgery branch at the National Cancer Institute between 1986 and 2006. Cancer 2008; 113:293.
- Atkins MB. Management of advanced renal cancer. Kidney Int 2005; 67:2069.
- Berger A, Brandina R, Atalla MA, et al. Laparoscopic radical nephrectomy for renal cell carcinoma: oncological outcomes at 10 years or more. J Urol 2009; 182:2172.
- Thomas AA, Rini BI, Stephenson AJ, et al. Surgical resection of renal cell carcinoma after targeted therapy. J Urol 2009; 182:881.
All topics are updated as new information becomes available. Our peer review process typically takes one to six weeks depending on the issue.