Kidney cancer

Diagnosis of kidney cancer is based on a urologic examination, which includes evaluation of the clinical history and physical examination, as well as radiologic studies. An abdominal ultrasound can raise the suspicion of kidney cancer and is the first level of diagnosis. All patients with suspected kidney cancer should undergo a contrast-enhanced CT scan or abdominal MRI. These examinations confirm the diagnosis and provide information on the size of the disease, anatomical features and the presence of signs of aggressiveness such as vein or lymph node invasion (local staging).

Depending on the individual risk profile of the patient, a chest CT scan and/or bone scan may also be required to assess if the disease has spread beyond the kidney (systemic staging). Comprehensive blood work should also be performed to assess the overall function of both kidneys. If accurate measurement of the contribution of each individual kidney is required, sequential renal scintigraphy is necessary. Very often, radiologic studies cannot determine with certainty whether the disease is benign or malignant, and microscopic analysis of the tissue is required to determine the histologic type of tumor. This information can be obtained by taking a biopsy from the lesion or by analyzing the entire lesion after it has been surgically removed. A nuclear medicine study called SPECT with sestamibi, which is a promising tool for distinguishing between benign and malignant forms, can still be performed in clinical trials at San Raffaele.

Possible treatments for kidney cancer include:

• surveillance, partial nephrectomy surgery;
• removal of diseased tissue only;
• radical nephrectomy;
• removal of the entire kidney;
• destruction by ablation and drug therapy.

There is no universal therapy, but the choice of optimal treatment is coordinated by a urologist with the help of other specialists, a radiologist, an oncologist and a nephrologist, based on the characteristics of each disease and each patient.

Active surveillance involves serious radiological monitoring over a period of time and is the strategy of choice for patients whose disease is relatively unaggressive compared to other general health problems. If there is a cancer risk, surveillance is discontinued and the patient becomes a candidate for active treatment.

When the goal of treatment is to cure localized kidney cancer, surgery is the method of choice. When possible, surgery includes removal of tumor tissue while preserving the remaining healthy kidney tissue (partial nephrectomy). The benefits associated with preserving part of the kidney tissue are reduced risk of postoperative renal failure, reduced risk of postoperative cardiovascular events, and in some cases even improved long-term survival rate. Partial nephrectomy is not always feasible, and in cases where part of the renal tissue cannot be saved, the procedure involves removal of the entire kidney (radical nephrectomy). All of these procedures can be performed with open surgery, traditional laparoscopic surgery or robotic laparoscopic surgery, depending on the experience of the surgeon.

Not all patients may qualify for surgery. Ablation involves destroying tumor cells with an external energy source. To treat the target tissue, it is necessary to reach the tumor with needles, using ultrasound or computed tomography as a guide. The quality of available studies on these techniques does not allow definitive conclusions, and this treatment is reserved for patients with health problems that define a significant risk of complications in the case of surgery.

If there is disease with distant metastases, treatment is determined by a multidisciplinary team involving a urologist and an oncologist. In some cases, treatment involves surgical removal of the primary kidney tumor and treatable metastatic lesions, followed by drug therapy as prescribed by the oncologist. In other cases, surgical treatment may not be of any benefit to the patient, then the patient is treated immediately with cancer drug therapy.

All patients undergoing the above treatment must be monitored by a urologist, a nephrologist and, if necessary, an oncologist.