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Renal Cell Cancer (cont.)

Exams and Tests

Only 10% of people with renal cell cancer have the classic specific symptoms, such as blood in the urine, or a lump or pain in the side. Other people have only vague, nonspecific symptoms, such as fatigue or just not feeling well. Still others have no symptoms at all. A health care provider will gather many different types of information to make a diagnosis. This process includes ruling out conditions that cause similar symptoms. If urinary symptoms occur, referral to a urologist (a doctor who specializes in diseases of the urinary tract) may be necessary.

The following steps may be taken for a health care provider to make a correct diagnosis:

Medical interview: A health care provider asks questions about the symptoms and how they started, current and previous medical problems, medications, family medical history, work and travel history, and habits and lifestyle.
Physical exam: This exam is performed to look for abnormalities that suggest a cause of the symptoms.
X-rays, a CT scan, and lab tests: These studies are usually performed after the interview and physical exam. If the results suggest that renal cell cancer or another cancer may be present, referral to a surgeon, a radiologist, and/or an oncologist (a doctor who specializes in cancer) may be needed.
Biopsy: A biopsy involves taking a small sample of the tumor. The sample is usually removed via a large needle inserted into the tumor. The sample is examined by a pathologist (a doctor who specializes in diagnosing diseases in tissues and body fluids). Cancer cells in the biopsy sample confirm the diagnosis of cancer. If the diagnosis of kidney cancer is strongly suspected based on x-ray/CT scan studies, biopsies of the kidney are not always done because of the risk of bleeding. The definitive diagnosis of kidney cancer is made at the time of surgery to remove the kidney (nephrectomy).
Staging: Another series of imaging studies and lab tests are performed to learn more details about the cancer and whether it has spread to other parts of the body. Careful staging is extremely important for planning treatment and predicting the course of the disease.

Imaging studies

A number of imaging studies are used to evaluate and stage renal masses.

Intravenous pyelogram (IVP): This study is also called excretory urography. A series of x-rays are taken of the kidneys, ureters, and bladder after a dye is injected into the bloodstream via a vein. The dye allows a much clearer and more detailed image of these organs than a regular x-ray. This study shows less detail than newer scans such as a CT scan and an MRI.
Arteriography/venography: This study is a series of x-rays of the blood vessels in and around the kidneys after injection of a harmless dye into the bloodstream. Like IVP, this study shows less detail than CT scans and MRIs.
Ultrasonography: This method uses sound waves (ultrasound) to create an image of the kidneys and surrounding tissues. This safe technique is the same method used to look at a fetus in a mother's womb. This method shows the difference between tumors and other abnormalities such as cysts.
Computed tomography (CT scan): This study is like an x-ray but shows greater detail than an x-ray and gives a 3-dimensional view of the kidneys and surrounding organs. CT clearly shows the difference between abnormal and normal tissues, and it also shows enlarged lymph nodes.
Magnetic resonance imaging (MRI): An MRI shows even more detail than a CT scan and shows if areas around the kidneys are affected by the tumor, especially blood vessels.
Positron emission tomography (PET): This study is recent technology that can show how tissues metabolize sugar. Because cancers take up and metabolize sugar differently than normal tissue, PET imaging can be useful in defining abnormal areas on a CT scan or an MRI.
Bone scan: A bone scan is recommended for anyone who has bone pain or other symptoms that suggest bone involvement. A chest x-ray or a CT scan can detect cancer spread to the lungs.

Lab tests

The following lab tests are performed to look for paraneoplastic syndromes, to rule out other conditions, and to evaluate a person's overall health before beginning treatment.

Urine analysis
Blood tests - Blood cell counts, chemistry, liver and kidney function tests, erythrocyte sedimentation rate, and prothrombin time and activated partial thromboplastin time (clotting studies)

Staging

Staging of renal cell cancer is based on the size of the tumor and the extent of its spread outside the kidney. Like many cancers, renal cell cancer is staged according to the tumor (T), nodes (N), and metastases (M) classification endorsed by the American Joint Committee on Cancer (AJCC). The TNM classification system assigns a T code, an N code, and an M code to each tumor. An X is used if that feature cannot be determined. The combination of these 3 codes determines the disease stage.

Primary tumor (T) - 0, 1, 2, 3a, 3b, 3c, 4; based on size of tumor and parts of kidney and surrounding area involved
Regional lymph nodes (N) - 0, 1, 2; based on number of lymph nodes involved
Distant metastasis (M) - 0 (no metastasis), 1 (metastasis)

AJCC stages

Stage I - T1N0M0; cancer is 7 cm or smaller in size and confined to the kidney
Stage II - T2N0M0; cancer is larger than 7 cm and confined to the kidney
Stage III - T1 or 2, N1M0 or T3a-c, N0-1, M0; cancer of any size that has spread to fatty tissue, blood vessels, or a lymph node near the kidney
Stage IV - T4; or any T, N2M0; or any T, any N, M1; cancer has spread to multiple lymph nodes; to nearby organs, such as the bowel or pancreas; or to other parts of the body, such as the lung, brain, or bone