indiacancer.org - Renal Cell Cancer (Rcc)

Renal Cell Cancer (RCC)

		What are the kidneys?
		What is RCC?
		How does RCC present?
		How is RCC detected?
		What is staging and grading?
		How is RCC treated?
		What are the side effects of treatment for RCC?
		What is the importance of follow up?

What are the kidneys?

The kidneys are two solid, bean shaped organs, placed in almost matching positions on the two sides of the back abdomen. They are approximately 5 inches wide and 3 inches thick.

The function of the kidneys is to filter the blood, retaining the essential elements and excreting or removing toxic waste products from the body in the form of urine. Each kidney has microscopic units called nephrons which perform these functions.

The urine then passes through two muscular, slim tubes (one arising from each kidney) called ureters, the top part of which is expanded to fit snugly into the inner portion of the kidney and is known as the renal pelvis. These then take the urine below to a reservoir called the urinary bladder, which holds the urine until it is voluntarily passed out of the body by us.

The Suprarenal Glands, The Kidneys, The Ureters & the Urinary bladder.

What is RCC?

The Kidney (Cut open).

RCC is a cancer arising from the cells forming the inner lining of the nephrons and their tubules. This is usually an adenocarcinoma, which means it has arisen from a glandular element.

Cancers arising from the subsequent portions of the urinary tract, that is the renal pelvis, the ureters and the urinary bladder are transitional cell carcinomas, as the lining cells here are transitional cells, a different cell type.

RCC may spread to other organs through the blood and the lymphatic system, to other distant parts of the body, such as the bones and the brain. This condition is called metastatic RCC. The cells lodged in the new organ are still RCC cells, and not bone or brain cancers.

How does RCC present?

	The most common symptoms of RCC are:
		Blood in the urine.
		A lump or mass in the side of the abdomen.
		A dragging pain in the side of the abdomen or in the back which refuses to go away.
		Tiredness.
		Loss of appetite.
		Anemia (too few oxygen carrying red blood cells).
		Unexplained weight loss.
	Sometimes, RCC can produce peculiar symptoms, which prima facie have no co-relation with the disease at all. These bizarre symptoms such as excessive calcium in the blood, or hypertension (high blood pressure) go by the name of paraneoplastic syndromes. Usually if therapy is successful, these syndromes to disappear.

How is RCC detected?

Besides the significant and obvious history given by the patient, the doctor may also perform a series of imaging investigations - ULTRASONOGRAPHY is the use of very high frequency sound waves that cannot be heard by the human ear. The ultrasound instrument sends sound waves into the patient's abdomen. The waves bounce off the internal organs and produce echoes that create a picture called a sonogram.

INTRAVENOUS UROGRAPHY (IVU) is a special X-ray investigation of the urinary system in which a special contrast dye is injected into a forearm vein and then as the dye passes through the kidneys, ureters and the bladder, X-rays are taken at different intervals of time. The whole tract is seen highlighted in this manner and most tumors can be picked up.

CAT (computer assisted tomography) scans are produced when the X-ray machine is linked to a computer. The X-ray machine is shaped like a large doughnut (Vada) with a hole. The patient lies on a bed which passes through this hole. As the patients body goes through it, the machine takes X-rays of different parts of the body. The computer then puts the X-ray pictures together to produce detailed, three dimensional pictures.

MRI(Magnetic Resonance Imaging) uses a powerful magnet linked to a computer. This large machine has space for the patient to lie in a tunnel inside the magnet. The machine measures the body's response to the magnetic field. The computer uses this information to create detailed, three dimensional pictures of areas inside the body.

The doctor may also decide to perform a renal biopsy using sonographic or CT guidance (a small piece of the lesion is removed with a needle, after localizing it using ultrasound or CT scan.) The tissue is then examined under a microscope by a pathologist to confirm the presence of cancer.

What is staging and grading?

These are terms with which you must become familiar, if you are dealing with any form of cancer.

When we stage a cancer, we try to establish carefully degree of spread of the cancer and if indeed there is spread, to what extent and involving which organs.

The grading of a cancer is a microscopic issue, in which the pathologist lets you know how aggressive this particular type of cancer is; well differentiated means less aggressive, moderately differentiated intermediately aggressive and poorly differentiated more aggressive.

Both grading and staging help your clinician to establish the prognosis or how serious your disease is and what is going to be the likely outcome.

Staging may require additional imaging tests such as CT Scan, MRI, Sonography of the abdomen, IVU, Bone scan or chest X-ray.

Stage I RCC
Cancer only in the kidney.

Stage II RCC
Has spread to the fat around the kidney, but has not breached the capsule surrounding the kidney.

Stage III RCC
Cancer has spread to the renal vein, the main blood vessel taking blood away from the kidney, and from there has spread to the great vessel taking the blood from the lower body to the heart (the inferior vena cava or IVC) or to lymph nodes around the kidney (Lymph nodes are small bean-shaped structures, which act as stations for drainage of lymph, a clear watery fluid, which courses through out the body in transparent, thin tubes called lymph channels or lymphatics,from various organs).

Stage IV RCC
There is spread to adjacent organs such as the vowel or the pancreas and to distant organs such as the lungs.

How is RCC treated?

	A lot depends on the patient's constitution, the grade of his disease and its staging. Patients are usually treated by a team of specialists which utilizes a multipronged approach. This includes an an oncosurgeon and a medical oncologist. Treatment strategies. Surgery is the bastion of treatment for RCC.
		Partial nephrectomy removes and part of the kidney. This is only done in special cases.
		Simple nephrectomy removes the whole kidney. The kidney on the other side can take over filtering the blood completely.
		Radical nephrectomy removes the kidney with the tissues around it. Lymph nodes in the area are also removed.
	Besides local therapy, the best attempt to control cancer cells circulating in the body and lodged at places other than the kidney is by using systemic therapy (therapy which affects the entire systems of the body) which is in the form of injections or oral drugs. This form of treatment is called chemotherapy.
	This form of treatment is given in a cyclical manner (each set of drugs is repeated usually after every 3-4 weeks. Chemotherapy can also be used in combination with surgery, radiotherapy or both, either before or after. The alternative local therapy to surgery is radiation therapy. This involves the use of high energy, penetrative rays to destroy cancer cells. It affects cancer cells only in the zone treated. Radiation therapy is also employed for palliation i.e. control of symptoms alone in an advanced cancer. Radiation therapy can also be used in adjunct to surgery or chemotherapy, either before or after. Teletherapy or external radiation is given via a machine remote from the body while brachytherapy or internal radiation is given by implanting a radioactive source within the involved tissues. Patients may or may not require both modalities of radiation. Radiotherapy, after initial planning, usually takes just 5 to 10 minutes per day, 5 days a week for about 6 weeks. This time period is flexible depending upon the modality of radiation used. Hormonal therapy uses hormones to control cancer cells and counter act their hormonal and paraneoplastic effect. Biological therapy employs Biological Response Modifiers (BRM's), which are substances that use the body's own immune system, either directly or indirectly, to fight cancer or to lessen the side effects of the anti cancer drugs. Some examples of BRM's are interferon-alfa and interleukin-2.
	Stage II.
		Radical nephrectomy.
		Teletherapy after radical nephrectomy.
		Partial nephrectomy.
		Palliative teletherapy.
		Arterial embolization.
	Stage III
		Radical nephrectomy. If the cancer has invaded the IVC, even part of this vessel may be removed.
		Arterial embolization.
		Palliative teletherapy.
		Palliative embolization.
		Biological therapy.
		Teletherapy before or after radical nephrectom.
	Stage IV
		Biological therapy
		Palliative teletherapy
		Simple nephrectomy, to relieve symptoms of the disease
		Radical nephrectomy with metastatectomy, if feasible. (Metastatectomy is removal of a metastasis).
	Recurrent RCC
		Biological therapy
		Palliative teletherapy
		Chemotherapy

What are the side effects of treatment for RCC?

	Surgery for renal cell cancer should be undertaken only in institutes which are experienced in this kind of surgery. The surgery can be very morbid in the wrong hands and it is one of the technically more difficult surgeries to perform. Often the result of surgery may also not be favorable if done by inexperienced hands. Unfortunately treatment for cancer does cause damage to the healthy tissues. Please ask the clinician about any possible side effects before any form of treatment commences. The commonest side effect is extreme fatigue. Although bed rest is good, most radiotherapists advise the patient to be as mobile as possible. Another common problem is that of radiation dermatitis in which the skin covering the radiated area becomes red, dry, itchy, and may show signs of scaling off. This will slowly settle down after radiation ceases, but there may be a permanent 'bronzing' of the skin. It is important to note here that this skin problem is associated only with teletherapy or external radiation therapy. Radiation also may cause nausea and vomiting, diarrhea, urinary discomfort. There may also be a fall in the white blood cells, which are needed by humans to fight infection. Usually the radiotherapist can suggest the drugs and diet necessary to alleviate such problems. Biological therapy The side effects commonly encountered with this therapy are as follows:
		Low grade fever
		Rashes and bruises
		Nausea and vomiting (usually mild)
	All these problems disappear on cessation of therapy. The various drugs in chemotherapy cause a varied spectrum of side effects. The severity and variability of these symptoms are very individualistic, changing from patient to patient. Some of the common side effects are:
		Skin rashes.
		Loss of hair.
		Diarrhea.
		Vomiting.
		Tingling and numbness in the fingers and toes.
		Hearing loss.
	Most are temporary and recede after therapy is over. Hair growth gradually starts after cessation of chemotherapy. The medical oncologist will usually be able to reduce the severity and spectrum of these side effects. The psychology of the patient is very important during therapy. Better psychologically prepared the patient is, better are his chances of having decreased side effects. The patient should drink large quantities of water while the therapy is in progress, and preferably avoid uncooked or raw food. Water should be filtered or boiled. Any relative or person who has any sort of infection such as common cold should be asked to desist from coming close to the patient.

What is the importance of follow up?

The importance of followup cannot be overemphasized. It is a fatal fallacy to assume on the patient's part that once the primary or the first phase of treatment is over, then he or she is cured. It must be stressed here that cancer has a notorious proclivity of coming back again and again. The only way to fight this is to pick up any problem when it is still early, so that it can be nipped in the bud. And the only way to do this is to follow up when the doctor calls you for the next visit. Each such visit will include a detailed history, a physical examination (including an internal i.e. a rectal or vaginal examination), a chest x-ray, an ultrasonography or a CT scan, and various other blood studies as indicated.