All You Need To Know About Renal Tumours
Know About renal tumours.
Renal tumours are very common tumours of the urinary tract in adults; it is supposed to be one of the most killer diseases of the urinary tract. When we are thinking about a renal tumour, bladder tumour or a prostate tumour which are different parts of our urinary tract which forms and throws out urine of the body, prostate tumours have a 5-year survival that means once a patient has been diagnosed with prostate tumour, which has not spread, the 5-year survival is 99%, same for a bladder tumour is around 80%, but for renal tumour it is 70%. That means out of 100 patients who are diagnosed to renal tumours, only 70 of them will survive for 5 years, 99 of prostate cancers will survive for 5 years, that is how aggressive this disease is, so it is important that we define this disease early, do whatever is needed so that it do not go to a stage where it is not curable.
If we talk about renal tumours, what are the causes or what are the factors, which leads to renal tumours? The most important agent of all cancers is tobacco. Chewing tobacco, smoking a cigarette has direct relation with renal tumours. Today, the incidence of renal tumour is increasing, it is said that obesity is the number 2 factor after tobacco for the increase in renal tumour; the third being hypertension. If you ask me whether renal tumours are familial or genetic or not – they are familial, they are genetic but the genetic cases are very rare. There is some disease known as tuberous sclerosis or von Hippel Lindau disease, which does cause renal tumours with a familial basis, so one in the family has it, the other person in the family may develop it, but basically, renal tumour is related to tobacco, obesity and hypertension.
If you ask me the incidence of renal tumour – it is, as I said, is quite frequent. If we have 100 patients adult with cancers, 3 of them will be renal cancers, so it is not so uncommon, 3 out of 100 is quite common, and this incidence is increasing today, not only because of the risk factors I have said, because imaging done for renal or non-renal causes are finding out more renal tumours. For example, today, if you go for screening for medical health checkup, a sonography is done. Now, since more and more patients are undergoing screening, more and more renal tumours are being detected and more will be detected in future, so this gives us a dilemma about management.
How aggressive should we be in managing the renal tumour, is it really aggressive? Are there tumours which may not kill, which must be left aside? These are the questions which have to be answered. Some tumours are benign, benign means they will not kill, but some tumours are malignant and they will kill. So when we think of renal tumours, 20%, 20 out of 100 tumours are benign and 80 out of 100, a large majority, a vast majority are malignant, malignant means they can kill. How do we differentiate between whether it’s a malignant tumour or whether it’s a benign tumour, this is the most important question once a tumour is detected on screening or when they have symptoms early. That’s why renal tumours are detected early, in early stages, in a stage where the tumour will be curable, or it is detected on screening with a sonography for health checkups again where it is curable. That’s the beauty of a renal tumour that it can be diagnosed early, unless unlike tumours of the liver and pancreas which are very deadly because they are seldom diagnosed early.
So now, how does a urologist decide whether it’s a malignant tumour or a benign tumour? Today, the urologist basically employ imaging, imaging means CT scan or MRI to differentiate between the two. Biopsy do not have much role in it as of today because there are no specific diagnostic markers, meaning thereby that if I do a biopsy, I cannot 100% say that it is benign or malignant. I cannot say 100% it is benign and there is no cancer tissue in it, cancer tissue means something which can spread. That’s why imaging, as of today, is not a good marker for diagnosis or differentiation between a benign disease and a malignant disease, so what you do today is imaging. Now, once you do an imaging, to make it more simple, what you find out sometime is a cyst, cyst is water-filled cavity within the kidney or you find a solid tumour. For example, if I show you one picture, so this is a solid tumour in the kidney, there is no water inside it, so this is one, and there is another presentation in which there is a cyst inside the kidney, these two are different. When we have a solid tumour, the chances of malignancy is much, much, much higher, 90% of the solid tumours are malignant. But when we have a tumour filled with water, it maybe malignant or it may not be malignant. So when a tumour is solid like this, the chances of malignancy is very high and 90% of them will be cancerous, that means they can kill.
But when a tumour is staged in 1, 2, 3 and 4, Grade 1 is what I said is a simple cyst, simple means simple, nothing needs to be done, it is synonymous with a cortical cyst. Grade 2 tumour may require observation and a follow-up. Grade 3 tumour has 33% chance of being cancerous or malignant. Grade 4 tumour has 90% chance of being malignant or tumourous. So if there is a cyst in the kidney on a sonography, if CT says it’s a Grade 3 or Grade 4, it has to be treated, it cannot be left aside, it has to be dealt with. But if it is a Grade 1 cyst or a simple cyst, nothing more requires to be done.
So now, we have discussed a little about what is a malignant tumour, what is a benign tumour of the kidney, how will you find out which is a benign tumour, which is a malignant tumour. To summarize, solid tumours are all usually malignant 90% of the time. And the second point which we have discussed is that kidney tumours are always, almost always deadly, 80% of them are malignant and they have a low… they are aggressive tumours because out of 100 tumours which are diagnosed, which is confined only to the kidney, which has not spread, 70% may die of the tumour compared to prostate cancer in which only 1 out of 100 will die of the tumour.
So once we have diagnosed, what is the treatment modality, how do we treat it? As I said, diagnosis is always on the basis of imaging that is CT scan or MRI. Biopsy as of today, do not have much of role but one day it will have role, have more of role. So today, once we diagnose a tumour that is a solid tumour in the kidney or a tumour which is cystic and it has not spread out of the kidney, the treatment is surgical. So now this is something new, what is a surgery? Should we remove the kidney all or can we remove only the tumour and preserve the kidney, why it is important? Because God has given us two kidneys, these tumours are usually disease of old age, so with age, the kidney function goes down day by day, so if can preserve a part of the kidney without removing in toto then we are saving his renal function, he may not require a dialysis over 10 years. If you remove one kidney… So today, the treatment of choice should be trying to preserve the kidney.
So when you have a renal tumour what you can do is, in this patient, we have a renal tumour diagnosed today by means of 3 small holes in the abdomen, we can go inside and remove the kidney in toto. As you see, this is a very large tumour, so this is the tumour, this is the normal kidney, so nothing much will be left by preserving this normal tissue. So this is a large tumour, so what is the meaning of large? By definition if I say, tumour less than 4 cm, we should always try doing something which is… this is a small tumour, so we can remove off this part of the tumour and save the remaining part of the kidney, so this surgery in which we save a part of the kidney, removing the tumour which is oncologically safe also, is known as a partial nephrectomy. As you can see here, we are removing this part of the kidney, so this is good 2/3rd of the kidney can be saved. So this is feasible for small tumours, so this is a partial nephrectomy. To repeat, this is a total nephrectomy, the entire kidney is gone, the tumour is gone, the normal part of the kidney is gone because this tumour is large, it is more than 8 cm, so it is more aggressive and removing this will not preserve much. But if we have a small tumour like this in which we can remove off the kidney, the small tumours are less aggressive, so after removing the tumour, we can save this part of the kidney, this is known as partial nephrectomy, so we remove the tumour and preserve this part of the kidney.
There are two forms of treatment, one is radical nephrectomy, it can be done laparoscopically by means of key holes, there is a partial nephrectomy, again can be done laparoscopically but usually we prefer doing a partial nephrectomy in which the tumour is small. A small tumour less than 4 cm should always be treated with partial nephrectomy, even up to 7 cm can be treated with partial nephrectomy. If a good remnant renal or remnant is found, meaning thereby that after removing the tumour, if you can save a good amount of renal tissue, kidney tissue, should try for partial nephrectomy.
In this hospital, we are doing partial nephrectomy laparoscopically, thereby we are giving the patient the benefit of laparoscopy as well as preserving as much of renal function as possible. So about renal tumour, what is important is diagnosis. Diagnosis, whenever there is a bleeding, we diagnose by means of a sonography or patients are diagnosed with sonography screening. In this way, since we are getting renal tumours early, we are treating them better and we are diagnosing them. Now, two important things in renal tumour, one is which I have answered that is biopsy. Is biopsy required? As I said, biopsy is not specific, so biopsy will miss cancers that’s why we don’t do biopsy. We diagnose these tumours with imaging most of the time today. There is some confusion here but I’ll not go into that but 99% of the time, urologist deals with renal tumour with imaging. The next question is, is it okay if we don’t do anything and leave it aside? Yes, it is okay in old patient, somebody is 70-year-old and his tumour is small, you can do active management meaning thereby you can do a sonography every year, taking the risk that if the tumour is increasing in size or if something happens, we can deal with it rather than we can just keep it aside and do active surveillance every year preferably with a CT or a sono.
This is what I have to say about renal tumour in a gist. Hope this talk would help you in knowing more about renal tumour and doing more about if there is any family member suffering from the disease.