Kidney Cancer

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Diagnosis

If the physician suspects RCC, a series of examinations, procedures, and laboratory tests are performed to confirm the diagnosis. A thorough physical examination is performed to assess the patient's health and obtain information about symptoms and a medical history is taken to determine if there are risk factors for RCC.

Imaging Tests

One or more imaging tests are performed to obtain pictures of the kidney(s) and locate abnormalities. Some imaging tests require the injection of a special "tracer" material (dye or low-level radioactive isotope) into the patient's bloodstream.

Computed tomography (CT scan)
CT scan is a type of x-ray that produces a series of cross-sectional, three-dimensional images of internal organs and glands. It can detect tumors and, in some cases, lymph nodes enlarged by cancer.

Magnetic resonance imaging (MRI scan)
An MRI scan uses large magnets to project magnetic waves through the body and create computer-generated, cross-sectional images of internal organs.

Ultrasound
Ultrasound uses sound waves projected into the body to produce an image of internal organs, structures, and tumors. In this procedure, a gel is applied to the patient's pelvic and kidney areas, and a small device that emits ultrasonic pulses is slowly passed over the area. The sonic image produced is viewed on a monitor.

Intravenous pyelogram (IVP)
An intravenous pyelogram (IVP) involves injecting a dye containing iodine through a vein in the arm into the bloodstream. The dye eventually collects in the urinary system, where it improves the contrast for x-rays and produces a well-defined image of the kidneys, ureters, and bladder. By showing up as white on the dark x-ray film, the IVP can detect tumors or damage caused by a tumor in the kidney.

In some cases, the physician may request an arteriogram or venacavagram (IVP of the blood vessels that supply the kidneys) to look for tumors in the connecting arteries and veins.

Chest x-ray
A standard chest x-ray may be used to detect RCC that has has spread (metastasized) to the lungs or bones in the chest.

Bone scan
This nuclear imaging procedure is used to detect the spread (metastasis) of cancer to bones, when aggressive tumors and metastasis are suspected. In a bone scan, a small amount of low-level radioactive material is injected into a vein in the arm. This material discloses metastatic cancer, as well as some noncancerous diseases, in bones.

Laboratory tests

One or more laboratory tests are performed to confirm the presence of RCC.

Urinalysis
More than half of all patients with RCC have blood in the urine (hematuria). Often this blood is present in small amounts or diffused in the urine so that it cannot be seen with the naked eye (called microscopic hematuria). To detect hematuria, a chemical test of the urine is performed. On occasion, cells found in the urine are examined under a microscope for abnormalities. This procedure is called urine cytology.

Blood tests
Another laboratory procedure typically used in the diagnosis of RCC involves microscopic examination and/or chemical analysis of the patient's blood. These tests screen for the following conditions which may indicate the presence of cancer:

• Anemia (too few red blood cells; caused by internal bleeding, a common cancer symptom)
  
• Polycythemia (too many red blood cells; sometimes caused by cancerous tumors in the kidney that trigger the release of erythropoitin [EPO], a hormone that increases red blood cell production in bone marrow)
  
• Hypercalcemia (high blood calcium levels) and elevated liver enzymes
  

Cystoscopy
Blood in the urine can result from other health problems, such as kidney stones or traumatic kidney injury, so the doctor may order a cystoscopy to determine precisely where the internal bleeding is occurring. In cystoscopy, a long, thin, rigid or flexible optical scope is inserted through the urethra and into the bladder. The practitioner then makes a visual examination of the urethra, bladder, and kidneys to locate the site of bleeding.

Fine needle aspiration
RCC tumors are made up of cancerous (malignant) cells that grow into a mass. If a tumor is found through imaging or other procedures, a cell sample may be taken for microscopic examination.

Physicians usually avoid performing needle biopsies of suspected kidney tumors because of the risk for bleeding or other complications. Some tumors contain a fluid-filled cyst. A small amount of this fluid can be drawn out of the cyst for examination by a pathologist, who will look for and identify the cancer cells. This can help the physician determine an appropriate treatment plan. While no longer common, a similar technique can be used to collect a sample of solid tissue from a noncystic tumor.

Pathology

Cells that make up RCC tumors fall into four categories based on their appearance under microscopic examination:

• Clear cell
  
• Granular cell
  
• Mixed clear and granular
  
• Sarcomatoid or spindle type
  

Most studies suggest that the type of cancer cell indicates the relative aggressiveness of the disease.

Under a microscope, clear cell cancers are the least abnormal. They are round or polygon-shaped and contain an abundance of fat and sugar. The tumors they produce are yellow to orange in color. Clear cell cancers are thought to be the least likely to spread (aggressive) and usually respond more favorably to treatment.

Few tumors contain only clear cells, however. Darker granular cells usually are present to some degree. These have a larger, darker nucleus and are full of tiny pink granules called mitochondria. The tumors they produce tend to be gray to white in color. Mitochondria are small, oval bodies that provide energy for cell growth. Their presence indicates a more aggressive form of cancer.

Tumors that contain both clear and granular cells are considered mixed. This is the most common form of RCC and indicates the most aggressive form of kidney cancer.

Mixed tumors that contain spindle shaped, sarcomatoid cells have the least favorable prognosis. Although tumors composed exclusively of spindle cells are uncommon, the presence of sarcomatoid cells indicates a form of cancer that grows and spreads quickly.

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