Kidney cancer symptoms and treatment

This page presents information on the symptoms and treatment of kidney cancer.

Early kidney cancer may have no symptoms and is increasingly being diagnosed incidentally following abdominal imaging.

About half of all renal cell cancer(RCC) patients and 90% of renal pelvis cancer patients present with haematuria (blood in the urine). 1 A more common cause of haematuria is infection but all cases should be investigated, with urgent referral to a specialist for those over 50 with unexplained haematuria (microscopic or macroscopic). 2

Other common symptoms of kidney cancer include back pain, palpable mass, fatigue, weight loss, sweats and anaemia. About 25% of patients have distant spread at diagnosis, presenting with symptoms such as bone pain, pathological fracture or cough. 1

Diagnostic tests include intravenous urogram (IVU) with CT and/or ultrasound scanning of the abdomen and chest. MRI may give additional useful information. At present there is no reliable screening test available for kidney cancer. For inherited genetic susceptibility, annual ultrasound or MRI scanning is available for those over 40.

Surgery remains the most effective treatment for renal cell cancer. Laparoscopic nephrectomy is possible for all but the largest tumours, resulting in less post-operative morbidity and better cosmetic result. 3

Small tumours (less than 3cm) may be suitable for nephron-sparing surgery (partial nephrectomy). 4 For those refusing or unfit for surgery, tumour ablation with radio frequency ablation (RFA) or cryotherapy are an alternative for small tumours of 4cm or less. 5, 6

There is increasing recognition that a subset of renal cell tumours may have a slow natural progression with only 1% progressing to metastatic disease. 7, 8 This has resulted in the suggestion that elderly or unfit patients who have small renal lesions could undergo active surveillance, having been given full appreciation of the risks.

In patients fit for surgery presenting with metastatic disease, nephrectomy controls the primary tumour most effectively and may also control symptoms such as haematuria and renal pain. Renal artery embolism or occlusion leads to partial or complete infarction of the kidney and offers a chance of temporary control of symptoms where surgical resection is not possible. Metastectomy can be offered, particularly for isolated metastases. Reports of delayed disease progression after this type of surgery (5-year survival rates between 14% and 47%) are common, but there is no randomised clinical trial evidence to support this.

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Advanced RCC is largely resistant to both chemo- and hormone-therapy so other approaches are being tried. 9 Cytokine-based immunotherapy with either interferon-a or interleukin-2 show overall response rates of between 4% and 31% for metastatic RCC. 10 Interferon is used following nephrectomy for metastatic disease, or as first line treatment.

Newer agents for metastatic disease are oral multi tyrosine kinase inhibitors, sunitinib and sorafenib. 11 Sunitinib has been reported to extend progression-free survival with better quality of life than cytokine therapy and is recommended in Europe as first line therapy for metastatic disease. 12 However, these agents have yet to be approved by NICE, which is due to publish guidance on sunitinib, sorafenib, bevacizumab and temsirolimus for renal cell cancer in January 2009.

Radiotherapy can reduce the size of renal cell tumours before surgery, control local pain and bleeding, or relieve bone pain. Since RCCs are usually chemotherapy- and endocrine-insensitive, such treatments are not routinely recommended.

Treatment for renal pelvis cancer is similar to that for invasive transitional bladder cancer - typically surgery. TCCs are chemosensitive and treatment with regimes used for bladder TCCs may be helpful in the palliative setting. 13 Radiotherapy may be used palliatively for inoperable or recurrent disease. 10% of patients with renal pelvis cancer have synchronous TCC of the bladder and 50% will develop bladder cancer in the future, so repeated cystoscopies and cytological examination of the urine are important in follow-up.

Increasingly kidney cancers are being diagnosed at earlier stages and smaller sizes due to the increased use of imaging techniques. 14 Such tumours are more easily treated though for some patients with co-morbid conditions, active surveillance may be a better option. 15 For patients with advanced disease, new treatment options have become available both with immunotherapy and new molecular-targeted anti-angiogenesis drugs. 14, 16

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