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Kidney Cancer: Ask an Expert

Online Health Chat with Dr. Matthew Simmons

February 22, 2012

Introduction

Kidney cancer, which most often occurs in men 50 to 70 years old, rarely produces symptoms in its early stages. Eventually, though, a tumor in one of the kidneys may trigger one or more of the following:

  • blood in the urine (most common symptom)
  • persistent pain in the back, just below the ribs
  • a lump in the abdomen
  • general symptoms such as persistent fatigue, unexplained weight loss, recurrent fevers, high blood pressure, and swelling in the ankles

Being aware of these signs can help patients catch their condition and begin treatment as soon as possible.

Options for treating kidney cancer include surgery to remove the kidney, chemotherapy, radiation therapy, hormone therapy, and immunotherapy. Sometimes, when the disease is tightly confined, treatment may involve removing only the affected portion of the kidney. This procedure, which was pioneered at Cleveland Clinic, is called a partial nephrectomy or nephron-sparing surgery and can help preserve the function of the involved kidney.

We encourage you to take this opportunity to ask a kidney cancer specialist your questions regarding treatment options, symptoms, and diagnosis.

Matthew Simmons, MD, is a urologist in Cleveland Clinic’s Glickman Urological & Kidney Institute. He specializes in the treatment of kidney cancer, prostate cancer, BPH, bladder cancer, and testis cancer. He also specializes in minimally invasive and robotic oncology surgery and minimally invasive robotic reconstructive surgery. Dr. Simmons joined Cleveland Clinic’s staff in 2009.

If you would like to make an appointment with Dr. Simmons or any of the urologists in the Glickman Urological & Kidney Institute, please call 800.223.2273, ext. 45600, or request an appointment online by visiting www.clevelandclinic.org/appointments.

Cleveland_Clinic_Host: Welcome to our Online Health Chat with Cleveland Clinic specialist Dr. Matthew Simmons. We are thrilled to have him here today for this chat. Let’s begin with some of your questions.


Cancer Types

jes905: Can you talk about chromophobe type renal cell carcinoma?

Dr__Matthew_Simmons: Chromophobe carcinoma is a specific type of kidney cancer (also known as renal cell carcinoma or "RCC"). Clear cell RCC comprises about 80 percent of all RCC. Chromophobe represents about 10 percent of all RCC.

In terms of aggressiveness, chromophobe carcinomas tend to behave themselves. The risk for spread before and after treatment is somewhat less than for clear cell RCC and other subtypes. This doesn't mean the risk is zero, as there are reports of it spreading and causing major problems. If you have a diagnosis of chromophobe RCC, then you can breathe a bit easier, but you still will need to have regular imaging to check for recurrence.

dcp: My father has collecting duct carcinoma kidney cancer. Any information on this would be helpful.

Dr__Matthew_Simmons: Hello, and sorry to hear about this situation. Collecting duct is a very rare type of kidney cancer, and it tends to behave very aggressively. If it was caught early, then he would require complete staging and a radical nephrectomy. If it has spread, then he would need to see a medical oncologist as soon as possible. Best of luck with this.


Causes

rlfinely: I'm a 64-year-old male. Despite my thinking I was in perfect health, I recently underwent left radical nephrectomy. My doctor said he got all the cancer out and I don't need chemo or radiation therapy. He also said repeatedly he has no idea how the cancer originated. How can I prevent or be certain cancer won't attack my other kidney or other organs just as mysteriously?

Dr__Matthew_Simmons: The risk of cancer returning depends on the stage of the tumor. That should have been assessed by the pathologist after your surgery. In most cases, once the tumor is removed, it ceases to pose a risk. You would need to know the stage in order to assess your risk and also to assess how aggressively you should be checked with repeat CT scans over the long-term.

In terms of how kidney cancers arise, there is no known cause. We know that patients who smoke are at much greater risk. There are also reports of a higher incidence of this disease in people who work with certain kinds of textile dyes and industrial solvents. In the vast majority of patients, tumors arise for no particular reason. There are a few hereditary types of kidney cancer, but these are very rare and usually present as multiple tumors in both kidneys. From what you have said, I do not think there is any higher risk of cancer in your relatives. Healthy diet, active lifestyle, and regular check-ups will be your best defense in terms of prevention or early detection of a recurrence.


Symptoms

Aqua26: What are the true symptoms of kidney cancer? I've heard of abdominal swelling and blood in urine. Is that true?

Dr__Matthew_Simmons: In the old days before CT scan and MRI, there used to be what was called the "classic triad." Three symptoms most often found in patients with kidney cancer were blood in the urine (also known as "gross hematuria"), a mass in the abdomen that could be felt on exam, and abdominal pain. Unfortunately, the tumors must be quite large to generate these symptoms, and in most of those cases, it had spread and was untreatable.

Today, nearly 60 percent to 70 percent of kidney tumors are what we refer to as "incidental," meaning that they are detected on CT and MRI scans while looking for something else. These tumors tend to be small and highly treatable. In terms of symptoms, in the vast majority of cases there are none.


Related Disorders

ObserveMoore: What are early signs of a kidney infection?

Dr__Matthew_Simmons: Kidney infections tend to have pretty severe symptoms, so if a person has one it would be difficult to miss. Most of the time, the kidney infection is preceded by a urinary tract infection (also known as a bladder infection). Symptoms include pain with urination, burning, and a feeling like you have to urinate frequently and urgently. Bacteria can then back-track up to the kidney and establish an infection there. Symptoms of this (also known as "pyelonephritis") usually include fever, chills, nausea, and back pain. If you have any of these symptoms you should visit your doctor so that your urine can be analyzed and the appropriate antibiotics can be given.

ObserveMoore: One of my relatives has pain in her lower back and often has trouble urinating. Could this be a sign of a kidney problem?

Dr__Matthew_Simmons: This is definitely something that should be evaluated by a urologist. This could be due to an infection, a kidney stone, bladder dysfunction, or other problems. There are specific tests that can be done to identify the problem and improve her situation.

Yram22: My 21-year-old daughter had her wisdom teeth out 2 years ago, then gum infections treated twice with clindamycin, had C. difficile as a result, two rounds of metronidazole, and then felt a pinch in her neck and had left-sided paresthesia since then (face, arm, leg). Last year, she started having severe facial pain and ongoing dry eyes (despite Restasis® [cyclosporine ophthalmic] and punctal plugs). MRI and CT scans fine, but show an ethmoid cyst (ENTs think it’s nothing to be concerned about). Blood work all fine except one that showed fairly elevated p-anca levels (anti-MPO). Does this mean kidney disease? She is waiting to see a rheumatologist but can’t get in until December. Is it possible she is having referred pain? Do you have any other avenues/types of doctors you could suggest? Thank you so much for your help and advice.

Dr__Matthew_Simmons: I don't have a lot of experience with immunological disease, but it sounds as though you should see a rheumatologist soon. Many antibodies such as p-anca are "nonspecific," meaning that if they are elevated it could reflect a variety of things. Specific tests, such as creatinine, will be needed to assess kidney function, and that should be coordinated through the rheumatologist's office.

It is disheartening to imagine that no one can see you until December. I would call the physician's office and request an appointment be made much sooner. At Cleveland Clinic, we offer appointments the same or next day. Best of luck to you and your daughter.


Testing

ADM221: What tests should I have to see if my kidney cancer has spread? Does kidney cancer spread quickly?

Dr__Matthew_Simmons: The best way to detect recurrent cancer is using a CT scan. After your surgery, the number of scans you need and the timing of those scans would be determined by the stage of the tumors as determined by the pathologist after surgery.

Thankfully, kidney cancers tend to grow slowly. My practice is to get a chest X-Ray and a CT scan 6 months after surgery, and then repeat imaging 1 year after that. If the tumor was low stage, then I may stop imaging after the 2nd study. If someone has a more dangerous tumor, then repeat imaging may be needed lifelong.

wphclw: I had a nephrectomy last August. My post-op CT showed a spot on my lung. I subsequent CT was negative. I recently had another CT with results of another spot on my lung in a different location. I was told to wait another 2 months for a repeat test. My question is this: is 2 months too long to wait for a follow up CT, and when should I be placed on medication?

Dr__Matthew_Simmons: CT scans are getting better as the years progress. Because of this, they are now able to detect very small things that could not be detected in years past. About 50 percent of my patients have mention of nodules in their lungs on their CT report. In the majority of cases, these are not cancer related. In your case, if they are small, then the best approach is to assess how they change over time. Two months may actually be too short an interval, as kidney cancer tends to grow slowly. In that regard, I think you are safe. It will be important to follow up with serial studies. If the spots get bigger over time, then a biopsy will be the next step.


Drug Therapy

Stappy: What is the difference between targeted therapy and biological therapy? I've researched both online but I'm still not clear.

Dr__Matthew_Simmons: Targeted therapy refers to treatment with a new class of drugs that block specific receptors in tumors cells that regulate their growth. There are many receptor types, and new drugs with varying specificities are being introduced.

I am unfamiliar with biological therapy. This may be another term that refers to targeted therapy. It may also refer to treatment of cancer with plant-derived homeopathic compounds. I would be wary of Web sites peddling these "remedies," as there is no clinical data supporting their effectiveness.

henderphil: I was free from kidney cancer for 18 years following a course of interleukin II. (I had had a 10 lb. tumor and kidney removed 6 years prior.) Tumors have now reappeared in my liver and abdomen. My oncologist has put me on Afinitor® (everolimus) 10mg. One other kidney cancer specialist wanted me to not have any treatment because of side effects, which would affect lifestyle. My oncologist has stated that if I did not go on it, the tumors would grow and possibly block my colon. I have been on it for two months and will shortly have a CT scan to see if there have been any results. Frankly, I am a little confused since I have two different opinions. How do you see it?

Dr__Matthew_Simmons: I am sorry to hear about this. In the past, interleukin therapy was used for metastatic kidney cancer, and only about 10 percent to 20 percent of patients demonstrated a response. That therapy was very toxic, meaning it made patients feel horrible, and because of its limited effect, it fell out of use.

A new generation of drugs called targeted kinase receptor inhibitors have emerged, and these are much better than older treatments. The drugs are taken by mouth in pill form, they have far less toxicity, and approximately 40 percent of patients who take them show a response. Unfortunately, there is no cure for metastatic kidney cancer, but use of these drugs can be effective in slowing down the process. My recommendation would be to continue the medication if you can tolerate the side effects. If on your next CT there is no response, you could switch to a different drug within that class such as Sutent® (sunitinib), as different tumors can respond differently to each drug. Best of luck to you.


Surgery

goodwin: I had surgery for kidney cancer about 8 months ago and still have pain in that side. Is this to be expected? My CT scan showed nothing there. Thanks.

Dr__Matthew_Simmons: Hello, and sorry to hear about this problem. In terms of recovery from a large flank incision, it can take several months. A normal CT scan should have ruled out a hernia, which would be the most concerning cause for incision pain. I would give this a few more months to resolve. (It can sometimes take up to a year.) If it has not improved, then I would see a pain specialist, as they may be able to better assess the problem and offer effective treatments.

Sydney: Do you perform robotic nephrectomies at Cleveland Clinic, and what is the benefit of having one versus an open procedure?

Dr__Matthew_Simmons: Partial nephrectomy was invented and pioneered at Cleveland Clinic. I have the privilege of learning how to perform them from Dr. Andrew Novick (the original inventor). The technique has evolved over the past decade so that now most of them are being done laparoscopically or robotically. I also had the privilege of learning how to do these with Dr Inderbir Gill, who invented laparoscopic partial nephrectomy. My decision regarding which technique to use, open versus robotic, depends on the size of the tumor, its location, and certain patient factors such as presence of pre-existing kidney disease.

Robotic partial nephrectomy is equal to open in terms of cancer control and preservation of kidney function. The benefit of robotic surgery is that the patient is able to avoid a large flank incision, which cuts through muscle. A flank incision is more painful than robotic port site incisions and can pose a much tougher recovery. Robotic surgery is not suited for every case, but whenever possible we use it to benefit our patients.

put54d: Looking for options other than surgery for an 11cm malignant growth on my right kidney, with the possibility that it has spread to my lung. Thanks. Any information would be appreciated.

Dr__Matthew_Simmons: I wish there were medical options for this, but surgery is the only effective treatment for kidney tumors. You need to know with absolute certainty if the cancer has metastasized. Your imaging should be evaluated specifically by an oncologist, medical or surgical, to be sure it has spread. If it has not, then surgery is your best (only) chance at cure.

If your cancer has spread, then there are two active treatment options. One option is to start targeted therapy, which involves taking a pill that blocks growth signaling in the cancer cells. The second option is to have what's called a "cytoreductive nephrectomy," in which the kidney is surgically removed followed by targeted therapy. There is data to support that the second option can prolong survival more than the first.


Post-Op

JacquieB: What is the average recovery time for a partial nephrectomy with an incision? I am an active 41-year-old woman and would like to know when I can expect to resuming certain physical activities.

Dr__Matthew_Simmons: I recommend no heavy lifting (heavier than a gallon of milk) for 8 weeks after surgery when a flank incision is present. This gives time for the incision to heal and decreases the risk for developing a hernia. Patients can expect to require pain medication for 1 to 2 months afterward. After the 8-week time period, I encourage patients to push themselves little by little. If something hurts, stop doing it, as your body is telling you something. If after 3 to 4 months the pain has not resolved, then I would contact your surgeon to have the incision re-evaluated.

JacquieB: Will my kidney function normally after the partial removal?

Dr__Matthew_Simmons: That is a great question, and is the topic of a huge amount of debate among urologists currently. The kidney should function at or near normal levels after partial nephrectomy. This is determined by the health of the kidney before surgery, the amount of time the kidney spent without blood supply during surgery, and the amount of tissue that was removed from the kidney. There is no question, though, that having a partial is better than having the whole kidney removed. Many studies have shown that patients with better kidney function have a lower risk of developing major diseases involving the heart and blood vessels. I would continue with regular check-ups, avoid high salt or protein diets, and if you have a decline in function, I would recommend that you be seen by a nephrologist at regular intervals.

justine: My father had a left kidney nephrectomy. The tumor they found was much larger than the scans indicated – about the size of a football? My father is 76 years old and was suffering the symptoms of this disease. My mother was not told much beyond that the operation went well. What types of questions should she be asking his doctor?

Dr__Matthew_Simmons: They should know that the surgeon has taken the tumor size and stage into account, and that he or she has used that information to design a follow-up protocol for him. Standard practice is to conduct a CT at 6 months after surgery, and this is usually followed by another scan 1 year after that. From what you have told me, it sounds like this tumor might have been higher stage. In that case, follow-up with repeat imaging is very important.


Staging

rlfinely: After having a left radical nephrectomy, my pathologist's report said my pTNM stage was pT3aNxMx. He also said my histologic grade (Fuhrman) was 3 or 4. Could you please explain this?

Dr__Matthew_Simmons: Cancer stage and grade give us an idea of the risk for cancer to return. It is based on something called the TNM staging system. The T refers to the tumor stage, the N refers to whether it involves lymph nodes, and the M refers to whether it is metastatic. Cancer stage refers to tumor size and it degree of invasion. In your case it is T3a. This means that the tumor was invading into the fat in the center of the kidney, and this is suggestive that the tumor may behave more aggressively. The Fuhrman grade refers to how the cells look under the microscope. Grade 1-2 tumors tend to be low risk, and those with Fuhrman grade scores of 3-4 are higher risk.

The most important aspect of your surgery was whether your surgeon was able to obtain a negative margin. This means that there was no tumor left behind after surgery. With a Grade 3, stage T3aNxMx tumor with negative margins the risk for recurrence or spread at 5 years is about 20 percent to 40 percent. Be sure to follow-up with your oncologist closely.


Risk of Metastasis

burtlake: I have a mass on my right kidney. It is approximately 3.2 centimeters. It is right in the center where the aorta enters the kidney. I am scheduled for surgery on 2/27/2012 to remove the kidney. I have had two similar opinions from urologists saying that they have to remove the whole kidney because of its placement and size. A CT scan shows that the left kidney looks healthy and that the mass is contained. Blood tests show that my liver is healthy, and X-ray shows that my lungs are normal. Could cancer have spread anywhere else? I was diagnosed 3 weeks ago. Are there any conditions that would make the cancer spread? Also, in situations like mine, what are the chances that I could get cancer in the remaining kidney?

Dr__Matthew_Simmons: There are many things to consider when making the decision to remove the entire kidney ("radical nephrectomy") or just the tumor ("partial nephrectomy"). Removing just the tumor is best because decrease in kidney function is associated with cardiovascular disease and other health issues. I cannot tell you if a partial nephrectomy is possible unless I could actually take a look at the images. I can tell you that we have the largest experience in the world with partial nephrectomy (it was invented at Cleveland Clinic), and that one of our specialties is partial nephrectomy for central tumors like yours.

In terms of stage, it sounds as though this is a stage t1a tumor. This means that if removed, there is a very low likelihood of it popping up again after treatment. The data supports a less than 5 percent chance of cancer returning within a 10 to 15 year period. I assume the other doctors have conducted imaging to stage the tumor. This means that they have verified that it has not spread anywhere. This is mandatory prior to proceeding with any type of treatment. I wish you the best of luck, and I invite you to see myself or one of my colleagues to assess whether the tumor could be treated with a partial nephrectomy.

kpn4: I had a partial nephrectomy on my right kidney in April 2010. I just had a CT scan where they found a 12mm lesion in my adrenal gland. This is also on my right side. What are the chances that this could be cancer? My follow-up appointment is next week, and I am feeling very worried.

Dr__Matthew_Simmons: It is possible that this is a metastasis, but more likely it may be a benign tumor called an adenoma. I would need to know the stage and grade of your kidney cancer to assess how likely it is that cancer has spread. In terms of diagnosing what the adrenal lesion is, that may be possible using the CT scan, but more than likely would require a biopsy. I have had several patients with this exact presentation. About half had a met and the other half had benign adenomas. Best of luck with this, and definitely seek additional opinions if you feel the need after your next evaluation.

gbf09: I have a 2.4cm tumor on my kidney that the doctors have been watching for over a year now. My doctor has said that they cannot tell whether it is malignant or not without removing it, but so far it has not grown at all. The doctor will remove it if I want him too. What would be your advice to one of your patients? Is it better to leave it alone since it is not doing anything or better to know if it is cancerous or not?

Dr__Matthew_Simmons: There has been a push in the urologic oncology community to watch small tumors in select patients. This approach is called active surveillance. Safety of this approach is based on data that show that small tumors <4cm tend to grow slowly (about 4mm per year), and that 80 percent of these tumors will pose little to no threat of metastasis. In patients who are older, or have major medical problems that make surgery more risky, this approach can be conducted safely. My preference is to biopsy these tumors whenever possible. That way we know exactly what we are dealing with, and can adjust the surveillance timing and aggressiveness accordingly.


Preventing Recurrence

edmorgan: Recently, I had a cancerous tumor removed from my left kidney. What strategies can I use to prevent a recurrence on either kidney (weight loss, diet, exercise, other)? How often should I be screened for a recurrence?

Dr__Matthew_Simmons: Your risk of recurrence is based on the stage of the tumor as determined by the pathologist after surgery. There is no way to prevent kidney cancer from forming. It is more a matter of avoiding risk factors, such as unhealthy diet and smoking. The "protocol" for following up after surgery with CT scans and chest X-rays is dependent on the tumor stage as well. Your surgeon should be able to explain this to you in detail, and you should come up with a definite plan for follow-up.


Dialysis

martinde59: My husband had a kidney removed a year ago at the Clinic due to a tumor. He is on dialysis and I wonder if his treatment would possibly remove cancer cells that might be circulating in the blood? Just was wondering. Thank you.

Dr__Matthew_Simmons: Hello, and sorry to hear about your husband's condition. Dialysis is designed to filter out tiny molecules such as potassium and keep in large molecules such as proteins. Cells are far too big to be filtered out by dialysis. Also, if his kidney has been removed, it is unlikely there are any cancer cells there now. One thing to consider is that patients on dialysis have a higher risk for developing new kidney cancer. If he had both kidneys removed this isn't a problem, but if he still has one it should be checked with an ultrasound once every 1 to 2 years.


General Questions

kolby3: I have a friend who was recently diagnosed with stage IV renal cell carcinoma with metastasis to the lung, lymph nodes, and brain. What are his chances (realistically) and what can I expect? I know each patient is different, but I will be sharing in the responsibility of caring for him and any information would be helpful.

Dr__Matthew_Simmons: Hello, and very sorry to hear about your friend. Sadly, there is no cure for metastatic renal cell carcinoma. Data supports that the average life expectancy after diagnosis is only about 13 to 16 months. Of course this is an average, and some patients may pass sooner or much later than that.

plato: Please discuss tumor necrosis. I’ve seen it a lot in my research.

Dr__Matthew_Simmons: Tumor necrosis occurs when a tumor outgrows its blood supply. When that happens the tissues in the center of the kidney are starved of oxygen and they die. This creates a zone of dead cells and tissue in the center of the tumor that has a characteristic appearance on the CT scan. In terms of the impact of this feature on how well patients do, there is an association of its presence with poorer outcomes. However, the association can vary, and for that reason, we rely mostly on tumor stage and grade as the basis for treatment decisions.


Closing

Cleveland_Clinic_Host: I'm sorry to say that our time with Cleveland Clinic specialist Dr. Matthew Simmons is now over. Thank you, Dr. Simmons, for taking the time to answer our questions today about kidney cancer.

Dr__Matthew_Simmons: Thank you for all of your questions.

Cleveland_Clinic_Host: Some participants have asked about upcoming web chat topics. If you would like to suggest topics, please use our contact link clevelandclinic.org/webcontact to submit your suggestions. In the question/comment section, choose Health/Disease Information so that we receive your comments.


More Information

If you would like to make an appointment with Dr. Simmons or any of the urologists in the Glickman Urological & Kidney Institute, please call 800.223.2273, ext. 45600, or request an appointment online by visiting www.clevelandclinic.org/appointments.

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Some participants have asked about upcoming web chat topics. If you would like to suggest topics, please use our contact link clevelandclinic.org/webcontact.