Kidneys are the bean shaped organ present in the back protected by the lower ribs and back muscles. Their main function is to filter the blood and thus helps in maintaining proper electrolyte balance. They also helps in maintaining the hemoglobin, body calcium and regulation of the blood pressure.
Tumor is an abnormal growth of the cells. They can be cancerous or non cancerous. Kidney cyst are the most common lesion of the kidney, they are fluid filled lesion and are usually benign. The Solid looking kidney tumors can be benign, but are usually cancerous 80% of cases.
The following associations may increase the risk of developing kidney cancer:
Ultrasonography is the initial test when kidney tumor is suspected once a lesion is confirmed further evaluation in the form of CECT abdomen or a MRI is done to evaluate the characteristic of tumor and its relation to the surrounding structures. Imaging (CT/MRI) of other organs is sometime needed to evaluate distant spread. Apart from the routine CBC, Urine Routine and renal function test, Chest X-ray, Liver function test are done to complete the metastatic workup.
Stage I:Tumor less than 7cm with no local or distant spread
Stage II: Tumor more than 7cm with no local or distant spread
Stage III:Tumor of any size which has spread to the regional Lymph Nodes or extended in to the renal vein or large vein ( IVC).
Stage IV:Tumor of any size or Lymph Nodes which has spread to the surrounding organs or to the distant organs.
Tumor which are confined to the kidney , three major modality of treatment exist
Tumor removal: Tumor removal is considered to be the standard of care for most of the renal tumor if it is feasible. If the tumor is very large than whole kidney along with the fat covering, part of the ureter and some time Adrenal is removed. With increasing incidence of Diabetes, hypertension, Bilateral tumors, patient with poor kidney reserve and other diseases there is trend to preserve as much kidney tissue (Nephron Sparing Surgery or Partial Nephrectomy) as possible provided it is feasible and safe to do so to prevent future renal deterioration and need for dialysis.
Open Radical Nephrectomy: Open Nephrectomy is usually performed by a flank incision around 5-8 inches long. The rib may be resected to facilitate the surgical maneuver. Kidney with the fat covering , ureter and sometime adrenal is removed after ligating the blood supply of the kidney. With a follow up 5-10 years most of the literature now favors partial nephrectomy (done in experienced hand) has got similar survival rate with less chance of patient going into renal compromise. Though the complication of partial nephrectomy are slightly high but if done in experienced hand are reasonable it is now considered to be the surgical procedure of choice for the tumor which can be resected with ease and safety. Partial nephrectomy is preferred treatment when radical nephrectomy results in either immediate dialysis or a high risk for subsequent dialysis, such as when the patient has a single functioning kidney, poor overall kidney function, medical or genetic diseases that threaten kidney function or bilateral kidney tumors. Not all the patient with renal tumor can undergo Partial nephrectomy. It is usually not recommended in patients with tumors that have extension into the renal vein, or tumor which are in close proximity to the main kidney vessels or factors that would make complete tumor resection unlikely. When ever partial nephrectomy is performed there is a small inadvertent risk of radical nephrectomy in case the tumor cannot be resected completely or risk of bleeding or other patient related complication ( risk of prolonged anesthesia, cardiopulmonary comorbities) .
SURGERY OR MINIMAL INVASIVE SURGERY:A slightly bigger cut is made to remove the final specimen, which depends on the size of the kidney and tumor. It is now considered as the standard for care for removing the kidney if feasible as have comparable oncological (Cancer Clearance) outcome as compared to the open technique. Not all renal tumor can be removed by the key hole surgery, tumor which are very big, or spread to surrounding organs or has extended into the major vessels of the body or patient related factor such as not poor cardiopulmonary reserve so as to cannot withstand the key hole surgery or multiple previous abdominal surgery.
Laparoscopic / Robotic partial nephrectomy:Partial Nephrectomy( Open/Laparoscopic/Robotic) is best suited for small, Exophytic (Bulging out of the kidney), peripherally located tumors that can be easily removed with minimal complication and better results.
Tumor ablation:Tumor ablation treatment destroys the tumor without surgically removing it by various forms of energy ( Hot or cold). Examples of ablative technologies include cryotherapy, radiofrequency ablation, high- intensity focused ultrasound (HIFU), microwave thermotherapy and laser coagulation. It is done by either open, Laparoscopic or percutaneous approach. No long-term studies are available as most of this techniques are new in the medical field but as compared to the standard surgical removal the recurrence chances are slightly higher. This is more suitable for patient which cannot tolerate major surgical treatment or patient with multiple bilateral tumors or small tumor recurrence.
Embolization:This is not considered as the standard procedure for the treatment of renal tumor. This is mainly done as a palliative care or in combination with other modalities. There main indication are tumor which are actively bleeding, thus by embolising the blood supply the bleeding can be stopped and physician have some time to stabilize the patient. They are also used for very large tumors to make them surgically amenable. This is mainly done by injecting embolising agent through a catheter inserted through the artery of the leg. Usually done under spinal in a radiology suite by interventional radiologist.
Open surgery is recommended for the tumor extending into the IVC (Largest vein of the body). An experienced urologist with a good institutional setup should do the surgery. The surgery requires isolation of the IVC and extracting the tumor and restoring back the IVC. This can lead to significant amount of blood loss and may require blood transfusion.
Tumor that have spread to other organs are treated by multimodal approach. Traditionally there are four primary treatment options: nephrectomy followed by immunotherapy, initial treatment with immunotherapy, targeted therapy, clinical research trials and surveillance.
Radiation:Radiation does not have any role in treatment of primary disease but usually it is used to alleviate the bony pain caused due to metastasis.
Surveillance:This is usually done when the probability of having a malignant tumor is low as in Angiomyolipoma decided based on imaging finding, or the size is very small , or the patient has very short life expectancy due to other causes or because of comorbities the surgical intervention carries high risk
After nephrectomy a regular follow up is necessary which consist of battery of blood test and imaging to rule out distant spread, local recurrence or early detection of tumor in the opposite kidney.
Kidney function:A person can lead a normal life he has one normal functioning kidney. But in some patient with already compromised function the risk of dialysis may be there. Patient with normal solitary kidney in whom a portion of kidney is removed during partial nephrectomy have 4-7% risk of becoming dialysis dependent a 3.6% risk of temporary dialysis with impaired function thereafter. There is also a risk of hyperfiltration injury in patient whose functioning renal parenchyma is less than the half of one kidney which can appear after few years. Patient needs to be on constant , regular follow up to diagnose and treat this complication earlier.
Prognosis:The two main factors affecting the prognosis of patient with renal tumor are the Stage of the tumor and the Grade. Higher the stage or the grade worse is the prognosis. The long term data of Laparoscopic radical nephrectomy is comparable to the open radical nephrectomy. The rate of tumor recurrence or spread in small renal tumor is comparable with the radical nephrectomy group. According to literature 18% of the renal tumor less than 4 cm can be benign which further strengthen the need to partial nephrectomy provided it is safe and feasible.
85% of the solid tumor, which enhances on CT scan is are cancerous. The dictum is unless proved otherwise the solid enhancing renal masses are malignant. There is a high false negative (6-15%) of renal biopsy ie, tumor is present but reported as normal or benign on biopsy. Thus there is high risk of missing cancers and there early treatment. There is also risk of bleeding, injury to the major vascular supply of the kidney needing nephrectomy apart from missing a tumor. Biopsy is indicated only when there is suspicion that the tumor have come from other organ ( Metastasis) or is a inflammatory mass or an abscess or is a Lymph node conglomerations based on imaging finding
Lymph nodes are the part of the immune system and the lymphatic channels carries excess body fluid from this. The fluid gets filtered in the LN. Some time the tumor cells gets entrapped in this LN and may result in forming a satellite lesion. The LN of the kidney are quite variable and does not take a particular course like other system. Moreover the hilar LN are usually removed during nephrectomy to prognosticate the patient. LN dissection is only required when there are obvious enlarged LN.
During traditional radical nephrectomy adrenal was being removed with the kidney. Of late literature suggest that there is no added benefit of removing adrenal in tumor located in the middle or lower part of the kidney (T1 and T2). Adrenals are usually removed only when the imaging studies suggest their involvement, or are enlarged or tumor is in upper part of the kidney or if tumor is T3, T4. This actually decreases the risk of adrenal insufficiency in future.
If the tumor is not a cancerous one, no further treatment is required. If the tumor is malignant most of the time surgical removal is the complete treatment. Patient with T3, T4 tumor or with distant metastasis may require additional targeted or immunotherapy after consultation with a medical oncologist.
Patient can lead a normal life with a single good functioning kidney. Even patient with mild suboptimal function usually does require dialysis but needs to be under the care of a nephrologist.
Patient needs to be a little extra careful when they have a singly functioning kidney and needs to avoid collision / contact sports which have risk of injury. Any medication consumed should be under the guidance of the physician and have to avoid painkillers and unnecessary use of other medications. They need to cut down on the salt intake. Patient should have a good control of their diabetes, hypertension and cholesterol. And need to be under regular follow-up to detect the renal impairment early.
There are no proven ways to prevent future recurrence other than stop smoking. Patient need to be under constant medical vigil to detect any recurrence or metastasis .
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