Among urological tumors, renal cell carcinoma (RCC) carries the worst prognosis because more than 40% of patients die of the disease as compared with the 20% mortality observed in prostate or bladder cancer (Capriotti, 2016). Renal cancer manifests in the kidneys as its first stages. To better understand renal cancer, it helps to know about the kidneys and what they do. The kidneys are a pair of bean-shaped organs, each about the size of a fist. They are attached to the upper back wall of the abdomen and protected by the lower rib cage. One kidney is just to the left and the other just to the right of the backbone. Small glands called adrenal glands sit above each of the kidneys. Each kidney and adrenal gland is surrounded by fat and a thin, fibrous layer known as Gerota’s fascia (Leibovich, 2018).
The kidneys’ main job is to filter the blood coming in from the renal arteries to remove excess water, salt, and waste products. These substances then become urine. Then the urine leaves the kidneys through long slender tubes called ureters which connect to each kidney at an area called the renal pelvis. The urine travels down the ureters to the bladder, where it is stored until you urinate. The kidneys also have other jobs such as helping control blood pressure by making a hormone called renin and they help make sure the body has enough red blood cells by making a hormone called erythropoietin. This hormone tells the bone marrow to make more red blood cells (Leibovich, 2018). Our kidneys are important, however we can function with only one kidney. Many people in the United States are living normal, healthy lives with just one kidney. Some people do not have any working kidneys at all, and survive with the help of dialysis. The most common form of dialysis uses a specially designed machine that filters blood much like a real kidney would.
There are several forms and variations of renal cancer. Renal cell carcinoma (RCC), also known as renal cell cancer or renal cell adenocarcinoma, is by far the most common type of kidney cancer. About 9 out of 10 kidney cancers are renal cell carcinomas. Although RCC usually grows as a single tumor within a kidney, sometimes there are 2 or more tumors in one kidney or even tumors in both kidneys at the same time. There are several subtypes of RCC, based mainly on how the cancer cells look under a microscope. Knowing the subtype of RCC can be a factor in deciding treatment and can also help your doctor determine if your cancer might be due to an inherited genetic syndrome. Clear cell renal cell carcinoma: this is the most common form of renal cell carcinoma. About 7 out of 10 people with RCC have this kind of cancer (Leibovich, 2018). When seen under a microscope, the cells that make up clear cell RCC look very pale or clear. Other types of renal cell carcinoma includes Papillary RCC and Chromophobe RCC.
The proximal tubule of the nephron is the origin of most RCC. Renal cancer occurs in a sporadic and hereditary form, both forms are associated with mutations of the short arm of chromosome 3, also called the VHL gene. RCC consists of malignant epithelial cells with clear cytoplasm that grow along blood vessels in the kidney. It is common for RCC to spread to various locations via the renal vein (Capriotti, 2016). The incidence of kidney cancer seems to be increasing. One reason for this may be the fact that imaging techniques such as computerized tomography (CT) scans are being used more often. These tests may lead to the accidental discovery of more kidney cancers. In many cases, kidney cancer is found at an early stage, when the tumors are small and confined to the kidney, making them easier to treat.
Most people who have renal cell carcinoma are older, usually between ages 50 and 70. It often starts as just one tumor in a kidney, but sometimes it begins as several tumors, or it’s found in both kidneys at once. Those who are affected with renal cancer include men more than in women (Wilkins, L. W.2014). Tobacco usage also plays a factor in causing renal cancer. The chemicals used in tobacco causes mutations in the cells in the body. Not only do chemicals in tobacco carry a risk factor for renal cancer but chemical exposure at jobs such as petroleum products, heavy metals and asbestos (Wilkins, L. W.2014). People who are obese also carry a higher risk factor for renal cancer. Obesity may cause changes in certain hormones that can lead to renal cancer. Another factor that may lead to renal cancer is unopposed estrogen therapy. Female hormones, such as estrogen also may play important roles during renal carcinogenesis and result in significantly different incidence rates between males and females. Other factors contributing to renal cell carcinoma are polycystic kidney disease, having high blood pressure, having a family history of renal cell cancer, having certain genetic conditions, such as von Hippel-Lindau disease or hereditary papillary renal cell carcinoma.
Many cases of renal cell carcinoma are symptomless until the condition is advanced. When symptoms do occur, they include flank pain, blood in the urine, or a lump in the abdomen. These and other signs and symptoms may be caused by renal cell cancer or by other conditions. There may be no signs or symptoms in the early stages. Signs and symptoms may appear as the tumor grow. Signs and symptoms are: Blood in the urine, a lump in the abdomen, a pain in the, side that doesn't go away, loss of appetite, weight loss for no known reason, anemia, fever, and flank pain in the abdomen (Wilkins, L. W.2014).
Renal cancer has various treatments ranging in length and effectiveness, however in order to determine which route of treatment to take, diagnostic testing must be performed to identify what treatment pathway to follow. A treatment route that is surprisingly uncommon was the subject of research in an article from 2016 titled, “Diagnostic Accuracy of Renal Mass Biopsy.” This journal effectively performs a study comparing and contrasting 100 different renal biopsies and charted effectiveness to display viability of this test.
Traditionally, labs and diagnostic procedures work in unison to narrow in on the issue and get rid of it efficiently. Lab tests that typically point out issues in the kidney are hypercalcemia (excess calcium), proteinuria (urine containing proteins), and hypoalbuminemia. The diagnostic procedures that are often used to zone in on the problem are CT scans, PET, IV pyelogram, arteriogram, venogram, ultrasound, MRI and lastly a tissue biopsy, which is only used in about 20% of all cases. On another note, out of all masses found, around 80% are potentially malignant.
In the research article titled above, the purpose was to compile results of biopsies to potentially prove how useful this test was an advocate for it to be used more that it currently is as it boasts an accuracy range of 73%-93% and may be the most accurate for determining tumor size and grade. Additionally, this test is viable for patients who are under surveillance or ablative therapy.
There are 5 standard treatments for renal cancer. The standard treatments used are surgery, radiation therapy, chemotherapy, biologic therapy, and targeted therapy. According to the National Cancer Institute, there is also treatment clinical trials that are aimed to improve current treatment or gain new information on new treatments (National Cancer Institute, n.d.).
Surgery involves the removal of part or all of the kidney. The different types of surgery available to treat renal cancer are partial nephrectomy, simple nephrectomy, and radical nephrectomy. A partial nephrectomy “removes the cancer within the kidney and some of the tissue around it. A partial nephrectomy may be done to prevent loss of kidney function when the other kidney is damaged or has already been removed” (National Cancer Institute, n.d.). A simple nephrectomy is the removal of only the kidney (National Cancer Institute, n.d.). The third type of surgery, radical nephrectomy, involves the removal of the “kidney, the adrenal gland, surrounding tissues, and nearby lymph nodes” (National Cancer Institute, n.d.).
Radiation therapy is another treatment to kill cancer cells or stop them from growing. The two types of radiation therapy available is external and internal radiation therapy (National Cancer Institute). “External radiation therapy uses a machine outside the body to send radiation toward the cancer” (National Cancer Institute, n.d.). “Internal radiation therapy uses a radioactive substance sealed in a needle, seeds, wires, or catheters that are placed directly into or near the cancer” (National Cancer Institute, n.d.).
Chemotherapy is used to “stop the growth of cancer cells, either by killing the cells or by stopping them from dividing” (National Cancer Institute, n.d.). The two types of chemotherapy are systemic and regional. Systemic chemotherapy is given orally or injection into a vein or muscle, so the drugs enter the bloodstream and reach the cancer cells throughout the body (National Cancer Institute). Regional chemotherapy involves placing the drug “directly into the cerebrospinal fluid, an organ, or a body cavity such as the abdomen, the drugs mainly affect cancer cells in those areas.” (National Cancer Institute, n.d.).
Biologic therapy uses the patient’s own immune system to fight the cancer (National Cancer Institute, n.d.). “Substances made by the body or made in a laboratory are used to boost, direct, or restore the body’s natural defenses against cancer” (National Cancer Institute, n.d.). There are three types of biologic therapy available. The three types are Nivolumab, Interferon, and Interleukin-2 (IL-2). Nivolumab boosts the body’s immune response against cancer cells (National Cancer Institute, n.d.). Interferon affects the ability of the cancer cells to divide which slows the growth of the tumor (National Cancer Institute, n.d.). Interleukin-2 increases the growth and activity of immune cells, especially the lymphocytes (National Cancer Institute, n.d.).
According to the National Cancer Institute, “Targeted therapy uses drugs or other substances to identify and attack specific cancer cells without normal cells.” Antiangiogenic agents are usually given with targeted therapy to treat advanced renal cancer (National Cancer Institute, n.d.). Antiangiogenic agents work by preventing blood vessels from forming inside the tumor, which can cause the tumor to stop growing or decrease in size (National Cancer Institute, n.d.). The two types of antiangiogenic agents used are monoclonal antibodies and kinase inhibitors. Monoclonal antibodies work by identifying substances on cancer cells and attaching themselves onto these substances to either block the cancer cells growth or keep the cancer cells from spreading (National Cancer Institute, n.d.). Kinase inhibitors keep the cancer cells from dividing or prevent the growth of new blood vessels that supply the cancer (National Cancer Institute, n.d.). The type of treatment used for patients with renal cancer depend on the stage of the cancer.
The most effective treatment for renal cancer is prevention. The nurse plays an important role in educating clients on methods to reduce their risk of renal cancer. Some modifiable risk factors that contribute to the development of RCC include smoking and obesity. The nurse should educate their clients who are at risk for RCC about smoking cessation or limitation and provide referrals to rehabilitation clinics who help with quitting the use of tobacco (Noble and Page, 2012). Clients at risk should also be educated on the importance of losing weight if they are obese or overweight. A referral to a nutritionist may help the client determine a new diet consisting of healthy eating or one that will help lead to weight loss. The nurse should also stress the need for exercise to help increase the weight loss results. Both the cessation of smoking and losing weight may help manage instances of hypertension which can not only lead to the decrease in their risk for RCC but also other complications such as cardiovascular diseases and diabetes (Noble and Page, 2012).
The nurse plays major roles in not only prevention, but the care and management of clients with RCC as well. There is a variety of decisions that the patient needs to make during the course of RCC in regards to treatments. Having a diagnosis such as RCC, may illicit fear from the client. It is essential that the nurse establish trust and rapport, be there for supportive measures, and to listen as the client expresses their fears and talks through options they have in order to make a decision. The nurse is responsible for educating the client on their treatment options (chemo, radiation, surgery, etc.), the risks, medications, and providing supportive care.
In the RCC patient who undergoes surgery, nursing care includes managing the client’s pain through pharmacologic methods as well as nonpharmacologic methods (relaxation, imagery, distraction, etc.). The nurse should encourage the use of an incentive spirometer to decrease the risk of respiratory depression, rotate positions regularly (every 2 hours), splint the incision when getting up or sitting down, and ambulate. The nurse needs to provide education to the client about how to manage wound/incision care so they can provide self-care when the are discharged. They need to be educated on refraining from any sort of heavy lifting, as well as driving, and managing their pain outside of the hospital. The nurse will teach the client of potential complications and when to call the doctor prior to discharge. The client needs to call the doctor if they develop a “fever, respiratory difficulty, wound drainage, blood in the urine, and pain or swelling of the legs” (Hinkle and Cheever, 2014). These complications could be a result of an infection from surgery, it is important to have the client seek medical treatment immediately.