Localized Kidney Cancer

Transcription

1 Patient Information English 3 Localized Kidney Cancer The underlined terms are listed in the glossary. If you are diagnosed with localized kidney cancer, your doctor can recommend treating the cancer with partial nephrectomy, radical nephrectomy, active surveillance, radiofrequency ablation, or cryotherapy. Each procedure has its own advantages and disadvantages. The choice of treatment depends on your individual situation. This section describes the different treatment options, which you should discuss with your doctor. This is general information which is not specified to your individual needs. Keep in mind that situations can vary in different countries. parts of your body. It may be a stage I or II tumour, depending on its size (Fig 1 and 2). tumour smaller than 7 cm kidney renal fascia adrenal gland vena cava aorta lymph nodes What is localized kidney cancer? renal vein ureter Localized kidney cancer refers to a tumour which is limited to the kidney and has not extended to other Fig. 1: A stage I kidney tumour is a tumour up to 7 cm, limited to the kidney. Page 1 / 14

2 adrenal gland tumour larger than 7 cm kidney vena cava aorta lymph nodes renal fascia renal vein ureter Fig. 2: Stage II tumours are still limited to the kidney, but are larger than 7 cm. Terms your doctors may use Nephron-sparing surgery: Another name for partial nephrectomy Open surgery: A surgical procedure in which the surgeon cuts skin and tissue to have direct access to the kidney Laparoscopic surgery: A minimally-invasive surgical technique in which the surgeon does not need to cut through skin and tissue. Instead, the surgeon inserts the surgical instruments through small incisions in your abdomen Surgical robot system: An instrument to help doctors perform laparoscopic surgery. The surgeon controls the robotic instrument with remote control sensors Page 2 / 14

3 Treatment options The best option for the treatment of a kidney tumour is surgical removal. These are some topics you should discuss with your doctor when planning your treatment pathway: Localized kidney cancer can be removed through either partial nephrectomy or radical nephrectomy. Both procedures can be performed by open or laparoscopic surgery. Laparoscopic surgery can also be done with the aid of a surgical robot system. During a partial nephrectomy only the tumour is removed, leaving the healthy kidney tissue untouched. This surgery is recommended whenever possible. If it is not possible to remove the whole tumour and leave part of the kidney intact, your doctor will recommend radical nephrectomy. This means that the kidney in which the tumour is located and the surrounding tissue are completely removed. Sometimes, surgery may not be the best option for you. This may be because of your age or medical condition, for example. If the tumour is smaller than 4 cm, your doctor may suggest a period of active surveillance. During active surveillance, your doctor schedules regular visits to monitor the tumour. If the tumour continues to grow you may need further treatment. A good option in this case may be ablation therapy. Your medical history If there are any cases of kidney cancer in your family What to consider if you only have one kidney Whether your kidney function is normal or if it has already been affected by other conditions like diabetes or high blood pressure Whether you have a tumour in one or both of your kidneys The kind of treatment available at your hospital The expertise of your doctor. Ask your doctor about his or her experience with the recommended treatment option Your personal preferences and values Support during and after treatment Ablation therapy can be either radiofrequency ablation (RFA) or cryotherapy. The aim of these procedures is to kill tumour cells by heating (RFA) or freezing (cryotherapy). Page 3 / 14

4 Partial nephrectomy Partial nephrectomy is a surgical treatment option for localized kidney cancer. It is recommended whenever possible. The aim is to remove the part of the kidney that has been affected by the tumour, and leave as much as possible of the healthy kidney tissue. For a partial nephrectomy you will receive general anaesthesia. During surgery you will lay on your side or on your back, depending on the location and the size of the tumour. How is partial nephrectomy performed? First, the exact location of the tumour is determined. A renal artery clamp is used to stop the blood supply to the kidney during the surgery to minimise blood loss. This allows for the removal of the entire tumour. Crushed ice is sometimes used to lower the temperature of the kidney during the surgery and prevent damage from lack of blood flow. After the tumour is removed the surgeon will suture the wound and apply sealing agents to stop further bleeding if necessary (Fig. 3). kidney tumour vena cava ureter needle holder Fig. 3: In partial nephrectomy the tumour is removed, leaving as much as possible of the healthy kidney tissue. Page 4 / 14

5 If the tumour has invaded the collecting system of the kidney, the surgeon may need to place a JJ-stent to make sure urine can flow through the urinary system. The stent will be removed when your wounds have healed and your urine flow is back to normal. This can take anywhere between several days and a few weeks (Fig. 4). kidney collecting system Partial nephrectomy can be performed as open or laparoscopic surgery. ureter Open surgery is the standard of care for partial nephrectomy. The surgeon cuts the abdominal wall to access the kidney and the tumour directly. JJ-stent Laparoscopic partial nephrectomy is a minimally invasive surgery. For this kind of procedure, the doctor inserts small plastic tubes into your abdomen. Through these tubes the surgeon can insert the instruments needed to remove the tumour. One of the small tubes is used to insert a camera which allows the surgeon to see a high-quality image of your kidney on a video monitor (Fig. 5). Laparoscopic surgery can also be done assisted by a surgical robot system. Laparoscopic surgery generally leads to faster recovery compared to open surgery, but the technique is demanding and your doctor needs to be experienced in this type of procedure. For the removal of a kidney tumour with partial nephrectomy, open and laparoscopic surgery are equally effective. How do I prepare for the procedure? Your doctor will advise you in detail about how to prepare for the procedure. You must not eat, drink, or smoke for 6 hours before surgery to prepare for the anaesthesia. If you are taking any medication discuss it with your doctor. You may need to stop taking it several days before surgery. urethra bladder Fig. 4: A JJ-stent is inserted to make sure urine can flow through the urinary tract. Page 5 / 14

6 guidance instrument surgical instrument Fig. 5: For laparoscopic surgery the surgeon inserts the surgical instruments through small incisions in the abdomen. What are the side effects of the procedure? Usually you can leave the hospital between 3 and 7 days after surgery. Keep in mind that the length of hospital stay can vary in different countries. After open partial nephrectomy, you may experience some pain on the side of your body for several weeks. Recommendations for 4-6 weeks after the surgery: Drink 1-2 litres every day, especially water Do not lift anything heavier than 5 kilograms Do not do any heavy exercise Discuss any medication you are taking If necessary, discuss the date to remove the JJ-stent with your doctor You need to go to your doctor or back to the hospital right away if you: Develop a fever Have blood in the urine Have heavy blood loss or pain Read more about support after surgery in the Support for localized kidney cancer section. What is the impact of the treatment? Partial nephrectomy is a common procedure for localized kidney cancer. More than 95% of patients remain cancer free up to 5 years after this surgery. The benefit of having two functioning kidneys after surgery contributes to overall kidney function and general health. What will the follow-up be like? After partial nephrectomy for kidney cancer, your doctor will plan regular follow-up visits with you. How often these visits are needed depends on the classification of the removed tumour (See: Diagnosis and classification). Follow-up lasts at least 5 years. Common tests during follow-up visits are abdominal CT and ultrasound scans, chest x-ray and urine and blood analyses. Page 6 / 14

7 Radical nephrectomy Radical nephrectomy is a surgical treatment option for localized kidney cancer. The aim is to remove the whole kidney and the surrounding fatty tissue. This surgery is performed when it is not possible to remove the tumour and leave part of the kidney intact. It is generally recommended for kidney cancers in stage II, or for stage I tumours when partial nephrectomy is not an option. Most people can live with only one functioning kidney without major complications. For a radical nephrectomy you will receive general anaesthesia. During surgery you will lay on your side or on your back, depending on the location and the size of the tumour. How is radical nephrectomy performed? First, the size of the tumour is determined. To prevent tumour spillage the surgeon keeps your kidney covered with a protective layer of fatty tissue. The surgeon then separates the renal artery, renal vein and ureter from the kidney (Fig. 6). Finally, the kidney is removed. tumour clamped renal artery clamped renal vein kidney clamped ureter Fig. 6: The tumour is removed together with the whole kidney. Page 7 / 14

8 Radical nephrectomy can be performed with laparoscopic surgery. For this kind of surgery, the surgeon inserts small plastic tubes into your abdomen. Through these tubes the surgeon can insert the instruments needed to remove the kidney. One of the small tubes is used to insert a camera which allows the surgeon to see a high-quality image of your kidney on a video monitor (Fig. 5). The laparoscopic procedure generally leads to faster recovery than open surgery. Nevertheless, the technique is demanding and your doctor needs be experienced in performing this type of surgery. Laparoscopic radical nephrectomy can also be done assisted by a surgical robot system. Open radical nephrectomy may be recommended in certain medical cases or if laparoscopic surgery is not available in your hospital. For open radical nephrectomy, the surgeon cuts the abdominal wall to access the kidney directly. The procedure has a longer recovery time and there is higher risk of pain or complications after surgery compared to laparoscopy. For the removal of a kidney tumour with radical nephrectomy, open and laparoscopic surgery are equally effective. How do I prepare for the procedure? Your doctor will advise you in detail about how to prepare for the procedure. You must not eat, drink, or smoke for 6 hours before surgery to prepare for the anaesthesia. If you are taking any medication, discuss it with your doctor. You may need to stop taking it several days before surgery. Recommendations for 4-6 weeks after the surgery: Drink 1-2 litres every day, especially water Do not lift anything heavier than 5 kilograms Do not do any heavy exercise Discuss any prescribed medication with your doctor You need to go to your doctor or go back to the hospital right away if you: Develop a fever Have heavy blood loss or pain Read more about support after surgery in the Support for localized kidney cancer section. What is the impact of the treatment? Radical nephrectomy is a common procedure for localized kidney cancer. Around 90% of patients is still cancer free up to 5 years after surgery. Because you are left with one functioning kidney, there is increased risk of chronic kidney disease. Reduced kidney function is also a risk factor for cardiovascular disease. What will the follow-up be like? After radical nephrectomy for kidney cancer, your doctor will plan regular follow-up visits with you. How often these visits are needed depends on the classification of the removed tumour (See: Diagnosis and classification). Routine follow-up lasts at least 5 years. Common tests during follow-up visits are abdominal CT scans, ultrasound, chest x-ray, and urine and blood analyses. What are the side effects of the procedure? Usually you can leave the hospital between 3 and 7 days after surgery. The length of hospital stay can vary in different countries. You may experience minor pain in the side of your body for some weeks after open radical nephrectomy. Page 8 / 14

9 Active surveillance Active surveillance is a form of treatment for localized kidney cancer in which the doctor actively monitors the tumour. It is recommended if surgery is not the best option for you and you have a tumour in your kidney which is smaller than 4 cm. Options for further treatment include surgery to remove the tumour or the whole kidney, or ablation of the tumour by cryotherapy or radiofrequency ablation (RFA). Factors which influence the decision for the best treatment option include: Some of the reasons why your doctor may say you are unfit for surgery include your age or any medical conditions which make surgery dangerous for you. To determine if active surveillance is an option, your doctor may want to perform a renal tumour biopsy. The tumour tissue taken during biopsy is analysed to make sure it is not aggressive. If the tumour is aggressive and surveillance is not an option for you, you may be recommended further treatment. Your age Other medical problems you may have The location of the tumour The subtype of the tumour If surgery is selected, partial nephrectomy should be favoured whenever possible. During this surgery, the tumour is removed but the surgeon leaves as much as possible of the healthy tissue of the kidney intact. If you are a good candidate for active surveillance, your doctor will set up a strict visiting schedule. On each visit, the urologist asks questions about any noticeable changes in your health, performs a physical examination, and discusses the results of your blood tests. Before each visit you get a CT or an ultrasound scan of your abdomen to monitor the growth of the tumour. An x-ray of your chest may also be done to check your lungs. In most cases, a follow-up visit is needed every 3 months in the first year after diagnosis. In the following 2 years the visits are scheduled every 6 months, and then once a year. In general, small kidney tumours tend to grow slowly and the cancer rarely spreads to other organs. If tests during follow-up show that the tumour is growing fast, or if you develop symptoms which may indicate the disease is advancing, the urologist will immediately plan further treatment. Page 9 / 14

10 Radiofrequency Ablation Radiofrequency ablation (RFA) is a treatment option for kidney cancer. It uses the heat produced by high-frequency radio waves to kill the cancer cells. The radio waves reach the tumour through a needle. Usually RFA is performed through the skin and the doctor uses ultrasound or a CT scan to guide the needle (Fig. 7). In order to know the subtype of the tumour, a biopsy is generally performed before starting the treatment. For this procedure you usually receive local anaesthesia, but in some cases general anaesthesia is necessary. RFA can also be performed during laparoscopic or open surgery. Your doctor may suggest RFA treatment if you have a small kidney tumour (less than 4 cm) and surgery is not an option for you. This may be related to your age or any medical conditions which make surgery dangerous for you. RFA is an effective and safe treatment for a small kidney tumour but there is a risk that tumour cells are left in the kidney after RFA. This means that the chance of recurrence is higher than after surgery. While the procedure is safe, there are risks of complications. The most common complications include pain around the treated area and a prickling or tingling sensation of your skin, known as paraesthesia. Bleeding can also occur, and in rare cases it may lead to a blood transfusion. After RFA, urine can leak and collect around the kidney. During treatment, your ureter, spleen, liver, or bowel may be injured. After RFA, follow-up visits are scheduled every 3 months. During these, CT or MRI scans are used to monitor your kidney and detect possible tumour recurrence on time. RFA can be performed more than once, in case of tumour recurrence or if the first treatment was unsuccessful. needle tumour kidney Fig. 7: Ablation therapy kills tumour cells by either heating or freezing. Page 10 / 14

11 Cryotherapy Cryotherapy, also known as cryoablation, is a treatment option for kidney cancer. It uses a liquefied gas, most commonly liquid nitrogen or argon, to kill tumour cells by freezing them. The liquefied gas reaches the tumour through a needle (Fig. 7). In order to know the subtype of the tumour, a biopsy is generally performed before starting the treatment. Usually cryotherapy is performed through the skin and the doctor uses ultrasound or a CT scan to guide the needle. Cryotherapy can also be performed during laparoscopic or open surgery. During the procedure the temperature of the kidney tissue and surrounding organs is carefully checked by thermo sensors. After cryotherapy, follow-up visits are scheduled every 3 months. During these, CT scan or MRI are used to monitor your kidney and detect possible tumour recurrence on time. Cryotherapy can be performed more than once, in case of tumour recurrence or if the first treatment was unsuccessful. Your doctor may suggest cryotherapy if you have a small kidney tumour (less than 4 cm) and surgery is not the best option for you. This may be related to your age or any medical conditions which make surgery dangerous for you. Cryotherapy is an effective and safe treatment for a small kidney tumour but there is a risk that tumour cells are left in the kidney after the procedure. This means that the chance of recurrence is higher than after surgery. While the procedure is safe, there are risks of complications. The most common complications include bleeding and a build-up of blood inside the kidney known as perinephric haematoma. During treatment, your ureter, spleen, liver, or bowel may be injured. You could also experience paraesthesia around the treated area, which is a prickling or tingling sensation of the skin. Page 11 / 14

12 Support for localized kidney cancer Getting diagnosed with cancer has a great impact on your life and the lives of your loved ones. It can cause feelings of anxiety, uncertainty, fear or even depression. Undergoing treatment for cancer is intense and will affect your work and social life. To find support, approach your doctor or nurse. They will be able to give you contact information about patient organizations or others who can help you with psychological support or practical matters such as financial advice. Preparing for a consultation Preparing for a consultation can be very useful. It will help you and your doctor better address your questions and concerns. Here are some things you can try: Write down the questions you would like to ask the doctor. This will help you remember things that you want to ask. Writing down questions can also help you organize your thoughts If you can, take someone with you to the visit. It is good to have someone to discuss what the doctor said and you probably remember different things Ask for information about your specific type of cancer If the doctor uses words you do not understand, ask for an explanation Tell your doctor what medicine you take and if you take any alternative medicine. Some of these medicines can affect the treatment After the consultation you can: Search the Internet or go to the library for more information about your type of cancer. Be aware that not all the information you see online is of good quality. Your doctor or health care team can point you to reliable websites Contact a patient organization, they can offer support and information Discuss with your health care team the possible financial consequences of your treatment. They might be able to direct you to people or places where you can get advice about your economic situation or even financial help If you want, you should ask for a second opinion from another specialist Support after surgery In the first days or weeks after surgery you may need help with everyday activities. If you can, ask family, friends, or neighbours to help you with things like buying and carrying home food, cooking, cleaning, washing, and gardening. You can also ask your health care team for information about professional home care. After surgery, it is common that you experience fatigue. This means you feel more tired than usual, you are out of energy, have trouble concentrating, and it doesn t get better after you sleep. Most people experience fatigue for six months up to a year after the surgery. To deal with fatigue, you can: Write down things that give you energy and give them priority during the day or week Get help with household tasks like washing, cleaning, or gardening Take short naps several times during the day Try to be as active as you can. A short walk every day is better than a long walk once a week When planning social activities like a trip or a visit, keep in mind you may need time to rest during the day. Discuss this with your family, friends or caregiver so that you can plan ahead. It is important to tell them when you are feeling tired Follow-up After surgery you will meet with your doctor. In this visit, both the results of the surgery and the followup schedule will be discussed. Ask for a care plan so you can see how often you will need to see your doctor, and what kind of tests could be needed before each visit. This depends on the characteristics of the tumour. Page 12 / 14

13 Write down questions you may have before the visit. Examples of questions you can ask are: Is the cancer gone? Do I need additional treatment? If so, what options are relevant for me? What kind of tests do I need before the follow-up visits? How will the treatment and the kidney cancer affect my quality of life? It is important that you continue to attend these visits. During these, the doctor monitors your kidney and can detect possible tumour recurrence on time. It is also important to tell your doctor if you notice any new symptoms. Do not hesitate to contact your health care team and tell them about new symptoms before the visit. Lifestyle advice It is important to maintain a healthy lifestyle during and after treatment. Try to get physical exercise regularly. Find an activity that you enjoy doing. If you have doubts about what you can do, ask your doctor to refer you to a physiotherapist. Try to eat a balanced diet with a mix of vegetables, fruit and dairy. Also include starchy food like bread and potatoes, rice or pasta, and protein-rich food like meat, fish, eggs, or legumes. Try to eat less sugar, salt, and fatty food. If you have any questions, ask your doctor to refer you to a dietician. Try to stop smoking. It may help you recover faster after surgery. Psychological support After the surgery you may worry about your prognosis, the impact of cancer on your financial situation, or other issues. It is common to worry about the cancer coming back. Most people who have been diagnosed with cancer, or their loved ones, will probably have these worries and thoughts. If you feel worried, contact your doctor and find out the risk of cancer recurrence. You can also ask the doctor about psychological support if you feel you need to have someone to talk to. A patient organization can also offer support. Surgery and cancer treatment can affect your sexuality. It is important that you talk to your partner about your feelings. There are many ways in which you can be intimate. If you do not want to be sexually active, be near each other, touch each other, give and take hugs, and just sit or lay down close to each other. During treatment you will be away from your work. Talk to your boss about the best way for you to get back to work. Perhaps you could work part time, or in a different function. Discuss the possible financial consequences of your treatment with your health care team. They might be able to direct you to people or places where you can get advice about your economic situation or even financial help. If you have difficulties getting back to normal life or getting back to work, talk to your doctor or nurse. They can help you find the support and treatment you need. A cancer diagnosis can make you look at life in a different way and you may realise you now have different priorities. This can affect your work or relationships and can make you feel disoriented and uncertain. Talk to family and friends and take all the time you need for this process. If you don t feel comfortable addressing these issues with those close to you, you can ask your health care team for a referral to a psychologist. The psychologist can give you the tools to deal with these feelings and help you to realise the changes you want or need. Support for family and friends A cancer diagnosis not only affects the patient, but also the people around them. As a loved one, you can Page 13 / 14

14 offer support in many different ways. Sometimes you can help with practical things like laundry, gardening, or grocery shopping. It may also be helpful to go to the doctor together. You could offer to drive to the visit or help formulate questions to ask during consultation. Being there for the consult can also be good. You may remember different things or focus on other details, which you can later discuss together. You could also ask the doctor how the treatment may impact your lives in terms of caregiving and psychological effects. The diagnosis and treatment can be very emotional for everybody involved. Cancer treatment is intense and your life may change suddenly. Questions about prognosis, effects of the treatment, and even the possibility of dying may come up. As a friend or loved one you can be there and listen. You don t need to have the answers. If you feel you need somebody to talk to, approach your family doctor or the medical team to get support. Patient organizations also offer support for family members or friends of people who have been diagnosed with cancer. These organizations can also help with more practical matters such as financial support. Testimonial Trevor P. (Aberdeen, Scotland) Just under 5 years ago at the age of 56 and in good health, I went to my doctor about a minor matter. I was sent for an ultrasound of my abdomen and by chance they saw something not so good in my right kidney. It turned out that I had a tumour of 5.6 centimetres in diameter. I was then scheduled to have a radical nephrectomy less than a month later. Because I read all information I could about my condition, I felt very positive throughout my waiting period before surgery and afterwards. I was very pleased when the surgeon confirmed that the cancer was contained within the kidney and completely removed during surgery, so I required no further treatment. Recovery was gradual at first, it was probably three months before I regained some strength and maybe a year before I was fully fit. From about 4 months I began to lead a normal life again. This information was updated in May This leaflet is part of EAU Patient Information on Kidney Cancer. It contains general information about this disease. If you have any specific questions about your individual medical situation you should consult your doctor or other professional healthcare provider. No leaflet can replace a personal conversation with your doctor. This information was produced by the European Association of Urology (EAU) in collaboration with the EAU Section of Uro- Oncology (ESOU), the Renal Cell Carcinoma Working Group of the Young Academic Urologists (YAU), and the European Association of Urology Nurses (EAUN). The content of this leaflet is in line with the EAU Guidelines. You can find this and other information on urological diseases at our website: Series contributors: Dr. Bülent Akdoǧan Dr. Sabine D. Brookman-May Prof.Dr. Martin Marszalek Dr. Andrea Minervini Prof. Haluk Özen Dr. Alessandro Volpe Ms. Bodil Westman Ankara, Turkey Munich, Germany Vienna, Austria Florence, Italy Ankara, Turkey Novara, Italy Stockholm, Sweden Page 14 / 14