There are 2 main types of primary kidney cancer. They are renal cortical tumors (renal cell cancer, or RCC) and upper tract urothelial tumors (transitional cell tumors). They are different in how they develop and change over time and in how they are treated.

Renal Cortical Tumors

More than 90 percent of kidney tumors are renal cortical tumors. They start in the main part of your kidney, which has structures called renal tubules.

There are many kinds of renal cortical tumors. They don’t all behave the same. The treatment you receive — including medications, imaging tests, and whether you need surgery — depends on the type of tumor you have.

Most types of kidney tumors are malignant (cancerous). However, some tumors are benign (not cancer). They usually don’t cause symptoms unless they grow to be very large. These benign tumors can’t spread to other parts of the body. They usually are removed through surgery and don’t come back. Examples of benign tumors include renal cysts, oncocytomas, and angiomyolipomas.

• Clear cell renal cell carcinoma (clear cell RCC)
• Papillary renal cell carcinoma (papillary RCC)
• Chromophobe renal cell carcinoma (chromophobe RCC)
• Oncocytoma
• Collecting duct tumors and renal medullary cancer
• Unclassified renal cell carcinoma (unclassified RCC)

Upper Tract Urothelial Tumors

This type of kidney cancer starts in your renal pelvis. That’s where urine collects before it goes into the ureter, a tube that connects the kidney to the bladder. Urothelial tumors affect the lining of the urinary tract, including the renal pelvis, ureters, bladder, and urethra. Urothelial (transitional cell) tumors are different from renal cortical tumors. They come from a different type of cell and behave more like bladder cancer.

The surgical strategy for these cancers is slightly different. To fight urothelial tumors that have spread, we use treatments developed for bladder cancer. Because of these differences, it is important to distinguish between renal cortical and upper tract urothelial tumors.

Testing can show if a kidney tumor is benign (not cancer) or malignant (cancerous). If it is cancer, we’ll find out the type of tumor and make a treatment plan that’s best for you. When we have an accurate diagnosis, we can be sure you get the most effective treatment.

Imaging

Imaging tests help us see inside your kidneys to look for cancer. Our kidney cancer experts often diagnose a kidney mass by repeating imaging tests that were done elsewhere. Our expertise can help you avoid a biopsy or surgery.

There are many kinds of imaging tests, including:

• CT scan: This test uses x-rays to take pictures of the body. To limit your exposure to radiation, we do this test only when necessary. We often use a contrast dye given intravenously (through an IV) to see the tumor better.
• Ultrasound: This test can tell if a mass in the kidneys is a fluid-filled cyst or a solid tumor.
• MRI scan: This test uses magnetism, not radiation, to make cross section images of your kidneys and adrenal glands.
• Cystoscopy: We place a small tube with a lens into your urethra (thin tube that carries urine from the bladder). This test lets us see your urethra and bladder.
• Ureteroscopy: We pass a narrow, lighted tube through your urethra and into the bladder, a ureter, and the renal pelvis.

Biopsy

We may recommend you get a kidney biopsy so we can tell if a tumor is cancerous.

During a biopsy, doctors remove a tiny piece of tissue from a tumor, usually through a hollow needle. A pathologist will then look at the sample under a microscope to see the cell types.

If the cells are cancerous, the pathologist will do more tests on the tissue to tell the type of kidney cancer.

The results of a kidney biopsy give us important information. They help us give you an accurate cancer diagnosis. The results also tell us whether you need more care, and options for surgery and medication.

Staging

Staging is how we describe how far cancer has advanced in the organ where it started, and whether it spread. We stage kidney cancer based on several things. This includes the size of the tumor, and the structures in and outside the kidney that are involved. We see if cells left the kidney and started to grow somewhere else, such as a lymph node or another organ.

• Stage 1 tumors are smaller than 7 centimeters at their widest diameter (about the size of an egg). They are only in the kidney.
• Stage 2 tumors are more than 7 centimeters. They are only in the kidney.
• Stage 3 tumors go through the renal capsule (the membrane on the outer surface of the kidney). They can extend into the fat and blood vessels around the kidneys, and in some patients, they may involve nearby lymph nodes.
• Stage 4 includes tumors in nearby organs or ones that spread to distant lymph nodes or other body parts. If the cancer has formed separate tumors in structures outside the kidney, it’s called metastatic disease.

Nearly 2 out of every 3 people with kidney cancer are diagnosed when they have stage 1 or 2 disease. About 15 to 20 percent are diagnosed when they have stage 3 disease. Around 15 to 20 percent are diagnosed with stage 4 disease. The 5-year survival rate is about 80 percent for all stages combined, but it varies greatly by stage.

Doctors gather information to predict how likely it is the cancer will advance and to choose the best treatment. They use information from mathematical models and lab test results. They also use details about the tumor, such as its stage, size, grade, and type.

At KIM’S, we tailor kidney cancer treatment to you, based on your needs and overall health. Our kidney cancer experts use a team approach. We look at information such as:

• Your diagnosis
• The type, size, and location of the kidney tumor
• How deep the tumor is in your kidney
• How the tumor has grown or changed over time
• Whether the tumor has metastasized (spread)
• Other health problems that may be affected by your treatment

Specialists in all areas of kidney cancer will make a treatment plan just for you. They are experts in pathology, medical oncology, surgery, interventional radiology, radiation therapy, and supportive care. They work together to give you the best outcome possible.

Our expert surgeons will evaluate your condition based on information such as the size and location of the tumor. Surgery is often all that is needed to remove kidney tumors that have not spread.

Your surgeon will choose the kind of surgery that’s best for you. We may do traditional open surgery or minimally invasive surgery. Minimally invasive surgery can mean a faster recovery and less pain. This method uses laparoscopic or robotic tools. With robotics, we make small incisions (surgical cuts) in the wall of your abdomen (belly).

• Partial Nephrectomy for Kidney Tumors
• Radical Nephrectomy
• Surgery for Upper Tract Urothelial Tumors
• Surgery for Kidney Cancer That Has Metastasized (Spread)

Radiation therapy can shrink or kill tumor cells. We may recommend radiation therapy if surgery isn’t an option for you.

Image-Guided Radiation Therapy

Radiation therapy uses high-energy beams to treat cancer. Image-guided radiation therapy (IGRT) can treat tumors with even more accuracy than traditional radiation therapy. IGRT involves taking many images of the tumor during treatment with a CT scan or x-rays. Your body is imaged in real time, so we can correct for any motion during treatment. IGRT lets your care team deliver radiation with great accuracy and precision.

Stereotactic Body Radiation Therapy

Stereotactic body radiation therapy (SBRT) is a form of treatment that delivers precise, high-radiation doses in 3 to 5 treatment sessions. It targets a small area with high doses of radiation and lower doses to the normal tissue around it. You can receive higher doses to the tumor at each treatment session, which shortens the overall treatment period.

This treatment is not invasive. You can usually have it as an outpatient, without a hospital stay.

The side effects from IGRT and SBRT often are mild. The radiation dose is precise and very concentrated, which is the best way to eliminate kidney cancer cells.

For patients who cannot have surgery to remove kidney cancer, we may offer targeted SBRT instead. We also can use these treatments on areas where the cancer has spread (metastasized), such as the bone or spine.

Systemic Therapy for Kidney Cancer

We use different treatments if the kidney cancer has spread through the blood and started new growth in other places. Your care team will talk with you about options for systemic therapy.

Systemic therapy is when medications are given intravenously (through an IV) or as pills. These drugs travel in the blood to reach cancer cells in different parts of your body. You will see your care team regularly while on such treatment, in order to make sure you are doing well and to make any adjustments that are needed.

If you are getting systemic therapy for metastatic kidney cancer, you will have imaging with CT or MRI scans done every few months. These scans help your care team monitor how well treatment is working.

The 2 main types of systemic therapy for kidney cancers are molecularly targeted treatments and immunotherapy. Cytotoxic chemotherapies are common for other cancers. They do not work for most types of kidney cancer, and we rarely use them.

Targeted Therapy

Targeted therapies are a standard tool we use to manage kidney cancer that spread to other body parts (metastatic disease). Targeted therapies have been available since the mid-2000s. Many of the targeted therapies available today originally were tested in clinical trials by doctors at KIM’S. These drugs are based on our deep understanding of the molecular changes in this kind of cancer.

Targeted therapies work by focusing on activities that drive the growth of cancer cells. Some target blood vessels that supply nourishing blood to tumors. Others directly block proteins that make kidney tumors grow and spread. Almost all targeted drugs are pills that you take at home.

Immunotherapy

Drugs called checkpoint inhibitors are standard treatment to manage kidney cancer that has spread to other body parts (metastatic disease). Checkpoint inhibitors are immunotherapy drugs given to you by infusion through an intravenous (IV) line into your vein. They work by taking the brakes off the immune system and allowing your own immune cells to attack your cancer.

Many kidney cancers have a lot of immune cells that are “asleep.” This type of drug can reactivate, or wake up, the immune cells to fight cancer and attract additional immune cells from other parts of your body. These medications often work well against kidney cancer.

They are given intravenously and require regular visits to the clinic. Treatments usually are given in an outpatient setting, with no need for hospitalization.

Systemic Therapy with Drug Combinations

The strategy behind drug combination treatments is to attack the cancer from different angles at the same time. Some treatments combine targeted therapies (pills taken at home) with immune checkpoint inhibitors (drugs given by IV in the clinic). Other treatments may combine 2 targeted pills or 2 intravenous drugs.