Surgery: Essential Standard Treatment

For kidney cancer which has not spread to distant sites (Stage I, II, or III - see Guide to Staging and Grading), surgery to remove the affected kidney (called nephrectomy) is the standard treatment and may well cure you. Surgery to remove a cancerous kidney is normally performed by a urologist, and although kidney cancer is not common, surgery to remove the affected kidney is often relatively straightforward, and can be routinely done locally. There are exceptions for complex cases (more detail below).

The chance of cure depends on how advanced your cancer is and on the sub-type (which won't be known till after surgery), but surgery is always your best shot if there is no sign of metastasis.

The Process

Being treated for localized kidney cancer comes in several phases. The exact details will vary considerably, but this section will give you an idea of what to expect.

Before Surgery

Pre-Surgical Testing: Once a suspicious mass has been found in your kidney you will undergo tests both to be sure the cancer has not metastasized to other parts of your body, and to define the extent of the tumor in your kidney, and also to help the surgeon plan your operation. The amount of additional testing to rule out metastasis and plan the surgery will depend on how advanced the kidney tumor is, as well as a careful evaluation of any other symptoms you might have. The results of your tests may prompt your doctor to order more tests.

Pre-surgical testing will usually include a CT scan of the abdomen and a chest X-Ray, as well as a careful physical exam and blood work. If the tumor is larger, you may get a CT scan of the chest, abdomen, and pelvis. Everyone gets a chest X-Ray before surgery. Your doctor may order other tests depending on your symptoms and how complex the surgery will be.

Biopsy: A common question is whether the kidney tumor should be biopsied before surgery to be sure it's cancer. In most cases it is possible to tell whether a kidney mass is malignant with high accuracy through CT scans and ultrasound scans. At the same time, needle biopsies are not infrequently falsely negative, so a biopsy usually is not useful for deciding whether surgery is necessary. If there is suspected metastatic disease, the situation is much different, and it may be useful to biopsy a suspected metastasis to confirm the diagnosis.

Two Things to Look Into Before Surgery

• Adjuvant Therapy: While drug or radiation therapy to prevent recurrence after surgery to remove the primary tumor is standard for many types of cancer, unfortunately there is no standard adjuvant therapy for renal cell cancer. There is a vaccine therapy which may be approved as a standard treatment in Europe soon, and which is available now in certain circumstances. There are also some opportunities in clinical trials which may be worth considering and, importantly, some trials require that you sign up before your surgery. For the details, see my article on Adjuvant Therapy.
  
  
• Preserving Your Tumor: Preserving your tumor may allow you to access advanced diagnostic tests when they become available in the future. If you have a recurrence, such tests may be important in making treatment decisions. If you want to preserve your tumor you must arrange it before your surgery. For the details, see my article, Put Your Tumor On Ice.

Waiting for Surgery: Years ago, cancer patients were rushed into surgery on the grounds that every day the tumor was there counted. These days, it's generally recognized that tumors take many years to develop and a few days wait is very unlikely to change the outcome. Especially in complex cases, one thing which surely can change the outcome is finding the right doctor and getting the right treatment. Therefore, you should not feel pressured into immediate surgery if you think there are issues which bear looking into (often there will not be!).

Surgery is often not scheduled for a few weeks anyway, but most patients would like to get it over with as soon as possible - waiting is hard! I had to wait for ten days and found that very difficult. Still, too long a delay cannot be good. If the delay will be more than just a few weeks, you should apply pressure for a sooner date and/or search for someone who can do it sooner. At the same time, knowing that you don't need to rush into surgery means you have a little time to find someone who you're comfortable with or get a second opinion or investigate your options if necessary. If you do have some time to wait, use that time to try to increase your strength every way you can - a healthy diet, light exercise, and stress reduction. If you smoke, consider taking this time to quit if at all possible.

Surgery

• Treating the Kidney Tumor discusses different kinds of surgery as well as some non-surgical methods that may be useful for a few people.
  
  
• Nephrectomy Tips gives you detailed practical suggestions on getting through your surgery and immediate recovery.

After Surgery

Long Term Follow-Up

After your surgery you will need life-long periodic follow-up to make sure your cancer has not recurred. There is no magic cure at five years with renal cell cancer, but the risk of a relapse is greatest in the first few years and declines over time. Follow-up includes a doctor's visit, blood work, and imaging scans such as CT scans or X-Rays.

Follow up will be more frequent and more intense the higher your risk which depends on stage, grade, and also your sub-type. The frequency and intensity of follow-up also declines over time as your risk declines. A future article will give more detail about typical follow-up schedules. In general, I think that finding metastasis early means a greater chance it could be addressed surgically and gives more time to try different treatments. This must be balanced against the psychological stress and cost of frequent scans.

Tip - Get Copies of Your Reports: Each scan or X-Ray is read by a radiologist who dictates a report. Your doctor will get copies of these reports. In addition, your doctor will have copies of the results of your blood tests. I suggest getting copies of these all of these reports from your doctor (who should be happy to provide them). Reading your reports will help you understand your situation in greater depth, and your own reading of the report provides a final check that nothing is being overlooked (I once noticed something on my bone scan report and when I pointed it out to the doctor along with symptoms he was concerned enough to order an MRI - which thankfully was negative). If you do have a recurrence, your reports will help you communicate essentials of your situation with potential second opinion or clinical trial doctors.

If at all possible, go over your reports with your doctor at your appointment so that any questions are answered immediately. Try to arrange the exam and visit for after the scans. I also arrange the blood draw the day of the scans so everything will be available at the visit. It can be psychologically hard to read these reports describing you, especially if they mention possible abnormalities. Radiologists go to great length to describe everything they see and scan reports often mention minor "nits" which sound scary to the uninitiated, but which aren't anything serious.

Living With One Kidney

What counts is how well your kidney or kidneys function to make urine and clean the blood of waste. It turns out that the kidneys have a great deal of reserve and one kidney can easily do the work of two as long as that one kidney is healthy. Actually, most people can have near normal kidney function with even just part of one kidney, something which is important for those few with tumors in both kidneys. As long as you don't have any disease affecting your kidney function (and renal cancer in one kidney doesn't count) your kidney function will almost always be normal or close enough with only one kidney. If you have a disease which impairs kidney function as well as renal cancer, you might have a problem.

For almost all of us, living with one kidney is almost exactly like living with two, only with fewer kidneys! Losing a kidney does not mean you will need a special diet or that you will have other special restrictions. Healthy people are even allowed to donate a kidney to a relative in need - something which wouldn't be allowed if losing a kidney had serious consequences. There are a few prudent precautions you can take.

• General Suggestions
  
  
  • Inform Your Doctors: Make sure any new doctor is aware of both the fact that you've had kidney cancer and that you have only one kidney.
    
    
  • Control Diabetes and High Blood Pressure: Both of these diseases can cause long term damage to the kidney and both require a long term commitment to control.
    
    
• Diet
  
  As long as you have normal kidney function no special diet is necessary, though it might be prudent to avoid long-term extreme protein intake. I would still urge anyone with a history of cancer to avoid junk food and eat a healthy diet with plenty of fresh vegetables and whole grains, and limited saturated or partially hydrogenated fat.
  
  
• Drugs
  
  
  • Beware of Over The Counter Pain Relievers: You should know that many over the counter pain relievers are somewhat toxic to the kidney. These non- steroidal anti-inflammatory drugs include aspirin, ibuprofen, and naproxen. Trade names for ibuprofen and naproxen include Motrin, Advil, and Aleve. Long term use of acetaminophen (Tylenol) has also been associated with kidney failure. Occasional short term use of these drugs is unlikely to be a problem, but self-prescribing long term or frequent use is a bad idea. Talk to your doctor if you're a frequent user of any of these drugs.
    
    
  • Other Drugs: Your doctor should take into account that you have only one kidney when prescribing drugs. I can't hope to try to research the list of drugs which can be toxic to the kidney, but you may want to double check drugs you've been prescribed just to be sure.
    
    
• Scans
  
  
  • CT Scans
    
    CT scans use an intravenous contrast agent which is hard on the kidney. The contrast agent makes blood vessels show more clearly. CT scans of the abdomen or pelvis also use an oral contrast which you drink (and sometimes also take by enema). As far as I know the oral contrast is non-toxic, and every bit as tasty as you'd expect an artificially flavored barium "milkshake" to be.
    
    
    • Communicate: At the time of the scan you should be sure to inform staff that you only have one kidney. A few centers prefer to use a half dose of contrast in people with one kidney.
      
      
    • Consider Non-Ionic Contrast: Non-ionic contrast isn't as hard on the kidney [Rudnick 1995] but isn't always used because it's more expensive. It's standard at many centers. If it's not standard at yours, consider asking your doctor to specify non-ionic contrast.
      
      
    • Hydrate! Drink plenty of water both before and after the scan to help your kidney flush the contrast agent. Often one is required to take nothing by mouth (Called NPO) for several hours before the scan. If this is the case, ask whether water is allowed. If not, just make sure you're well hydrated before the start of the NPO period and drink a lot as soon as the scan is over.
      
      
    • Take N-Acetylcysteine: This anti-oxidant has been shown in a randomized trial [Tepel 2000] to prevent renal toxicity due to contrast in patients with somewhat impaired renal function. As far as I know, Acetylcysteine is non-toxic so it seems like a prudent measure to take the stress off your kidney even if that kidney is working fine. N-Acetylcysteine is commonly available over the counter in the US as a "nutritional supplement" called "NAC" and it can be prescribed in liquid form as a drug called "Mucomyst". The liquid tastes horrible but the supplement is sold as pills or capsules.
      
      
  • Bone Scans
    
    Bone scans aren't usually part of routine follow-up after surgery for localized kidney cancer, but a bone scan may be used to investigate symptoms or things seen on other scans. Bone scans use a low dose of a radioactive tracer which is taken up by the bones. Increased uptake by an area of bone can signal a bone metastasis, though false positives are common. The tracer, Technetium-99m, has a short half life of only about six hours, and is injected about two hours before the scan. The delay allows the bones to take up the tracer.
    
    
    • Main suggestion: Hydrate! Tc99m concentrates in the kidney as well as the bones (as will be evident if you see the scan!). While the radiation dose should be low, it is still prudent to drink plenty of water both before and after the injection to help your kidney flush the tracer and its decay products. I would continue to drink extra water for twenty four hours after the tracer is injected.
      
      
  • PET Scans
    
    PET scans aren't used in routine follow-up but might rarely be used to investigate a possible recurrence. Like bone scans, PET scans use a low dose of a radioactive tracer, in this case Fluorine-18 coupled to a glucose (sugar) molecule to make a chemical called FDG. FDG is taken up by cells similarly to sugar and so it concentrates in metabolically active tissue such as tumors. Fluorine-18 has a radioactive half- life of a little less than two hours, but due to elimination from the body the effective half life is much less, often quoted as 20 minutes or so. This is where you can help.
    
    
    • Main suggestion: Hydrate! FDG concentrates in the kidney as well as in the target tissues (and for this reason cannot be used to image tumors that are actually in the kidney), so it seems prudent to hydrate before and after the test as for a bone scan. This is one scan I haven't had, so be sure to find out how close to the scan you can drink water.
      
      
  • Other Scans and X-Rays
    
    
    • Plain X-rays, including chest films, as well as ultrasounds do not use a contrast or tracer and so you don't need any special precautions. A contrast agent is sometimes used during MRI scans, but as far as I know it is not toxic and again I don't think you need to do anything special.
      
      
    • Other X-Ray procedures which use an IV contrast, such as angiograms, should be handled as I described for CT scan above.
      
      

References

Rudnick MR, Goldfarb S, Wexler L, Ludbrook PA, Murphy MJ, Halpern EF, Hill JA, Winniford M, Cohen MB, VanFossen DB.

Nephrotoxicity of ionic and nonionic contrast media in 1196 patients: a randomized trial. The Iohexol Cooperative Study.

Kidney Int. 1995 Jan;47(1):254-61. [PubMed Abstract (will open in new window)]

Comment: This study involved using contrast with a different type of diagnostic test, an angiogram, but the principle is the same as for CT scan. The patients who had known renal function problems or diabetes (which predisposes to it) got the most benefit. They didn't specifically test patients with one kidney with normal renal function, but it seems prudent to avoid stressing your one kidney more than is necessary.

Tepel M, van der Giet M, Schwarzfeld C, Laufer U, Liermann D, Zidek W.

Prevention of radiographic-contrast-agent-induced reductions in renal function by acetylcysteine.

N Engl J Med. 2000 Jul 20;343(3):180-4. [PubMed Abstract (will open in new window)]

Comment: This study was for patients with known abnormal renal function. The dose was 600mg orally twice per day, for two days, the day before the scan, and the day of the scan.

Free full text of this article is available from the New England Journal of Medicine's Web Site but you have to register first to get access. You might want to print out a copy for your doctor.