The field of medicine is dynamic , and the management of kidney cancer is no less , where change is the only constant . There was a time when kidney cancer was called “ HYPERNEPHROMA ” or “ GRAWITZ TUMOUR ” but now it is called “ RENAL CELL CARCINOMA ”. However , the change goes far beyond just the nomenclature . In this article , I would like to highlight the major changes related to this cancer .

CLINICAL PRESENTATION

In the past , kidney cancer would present with the classic triad of symptoms , i . e . Pain , Presence of a flank mass , and Passing blood in the urine ( which is otherwise known as haematuria ). Now , with the increasing accessibility of imaging techniques , including ultrasonography ( which is often available even in general practice clinics ), computer tomography ( CT ) & magnetic resonance imaging , the majority of kidney cancers are found incidentally when patients are asymptomatic . Detection of kidney cancers this way was approximately 10 % in the early 1970s , but this has risen to approximately 60 % in the 1990s . Despite this , patients still present with large and / or advanced kidney cancers as the tumours usually do not have any signs or symptoms in the early stage ( Figs . 1 & 2 ).

To facilitate this surgery , operating robots are also being employed to remove the tumour , especially the challenging ones . These machines operated by surgeons have the advantage of 3D vision , magnification and dexterity in performing complex surgeries .

IMAGING

Another factor that helps increase the success of performing partial nephrectomy is the development of modern imaging techniques . Once upon a time , the humble intra-venous pyelogram was used to detect kidney cancers . Now , we have contrast-enhanced CT scans which can be sliced into very fine cuts & even reconstructed into three dimensions . This helps the surgeon better assess the feasibility and execute the performance of challenging partial nephrectomies .

There is even intra-operative ultrasound , where a probe can be introduced into the patient ’ s abdominal cavity to locate and confirm the presence of kidney cancers which are deeply buried in the kidney .

Fig . 1 - Large right kidney cancer

Fig . 2 - Large right kidney cancer

Fig . 2 - Large right kidney cancer

FOCAL THERAPY

Another advancement in the treatment of small kidney cancers is focal therapy . For this , the tumour is ablated by introducing a probe into the tumour and then using energy to either heat the tumour ( radiofrequency ablation ) or freeze the tumour ( cryoablation ) to destroy the tumour cells . This approach is non-surgical and is advantageous for frail patients or patients who decline surgery for other reasons . However , there are no randomised studies to date to compare this approach versus surgery , thus precluding its universal application .

SURGERY

When tumours are detected earlier , they tend to be smaller ( Fig . 3 ). Surgical knowledge , equipment and technique have advanced so much that removal of the entire kidney may no longer be necessary . Partial nephrectomy , which involves removing only the tumour with a margin while preserving the rest of the healthy kidney , is becoming more common . Despite the added challenges & risks of performing partial nephrectomy , there is progress in doing it laparoscopically . So , instead of a large incision , the surgery can sometimes be performed through keyhole-sized incisions .

Fig . 3 - Small right kidney cancer

ONCOLOGY TREATMENT

In the past , chemotherapy and radiotherapy were ineffective in treating advanced and metastatic kidney cancer . Almost all were dependent on surgery alone , failing would mean the patient has no more effective option . Now , drugs have been developed to oppose the development and spread of cancer by working with the human immune system . With this advancement , there is more effective treatment for patients with advanced kidney cancers & even cancers that have already spread ( metastasized ).

With a better understanding of the disease process ( pathophysiology ), now some kidney tumours can be observed without any surgical intervention . Smaller tumours have a lower risk of spread . Also , for renal masses less than 4 centimetres , only about a quarter are overtly malignant ( i . e . aggressive cancers ) while the remainder are either benign ( i . e . non-cancerous ) or indolent ( i . e . cancers but they grow slowly ). Therefore , patients who are older , medically fragile , experiencing or recovering from a serious medical condition , or reluctant to surgery can be candidates for this “ active surveillance ”.

The other limit being pushed when doing partial nephrectomy is the size and location of the tumour . Previously , only small tumours less than 4 centimetres protruding from the kidney accessible and away from vital structures were subjected to this surgery . But now , larger tumours greater than or equal to 7 centimetres , those deeply embedded within the kidney parenchyma ( endophytic ), and those located posteriorly , centrally or close to the major kidney vessels are also being attempted to be removed partially ( Fig . 4 ).

Fig . 4 – Right kidney tumour > 4cm ; small left kidney tumour near the artery supplying the kidney

CONCLUSION

Much has developed in the case of kidney cancer . Detected cancers are getting smaller while surgical approaches are getting smaller too . All these are thanks to medical technology which has also given us medication that can prolong survival using the body ’ s immunity .

Dr . Teoh Boon Wei

MBBS ( Vellore ), M . Med ( Surg ) ( USM ), Cert ( MBU ), FRCS ( Urol ) ( Glasg ),

Fellowship in Urology ( Melb )

Consultant Urologist