• Diagnosis and Prognosis of Kidney Cancer

    Diagnosis begins with a visit to the doctor. Most of the time, kidney cancer is noted when an imaging test, such as a CT scan , is ordered for an unrelated reason. Kidney cancer may have many different symptoms, or no symptoms at all. Some of the symptoms include abdominal pain, blood in the urine, unexplained fever, and weight loss. However, each of these symptoms can be caused by conditions other than kidney cancer. The most common type of kidney cancer is called renal cell carcinoma, but there are several other types.
    The diagnosis and prognosis of kidney cancer includes the following:

    Medical History

    Your doctor will ask about your symptoms and medical history. He or she will ask when you first noticed the symptoms and how they have progressed. Your doctor will also ask about anything that may increase your risk of kidney cancer, including:

    Physical Exam

    The doctor will perform a physical exam, paying careful attention to any signs that may indicate kidney cancer, such as swelling in the legs or a lump in the abdomen.

    Testing

    Diagnostic tests may include:
    Blood and urine tests —These tests are used to check kidney function or to find substances that indicate kidney cancer may be present.
    CT scan —This is a type of x-ray that uses a computer to produce cross-sectional images of the inside of the body.
    Intravenous pyelogram (IVP) —For this test, a dye is injected into one of your veins and a series of x-rays is taken. The dye courses through the urinary system, allowing x-ray pictures to be more clear and detailed.
    Renal angiography —A dye is injected into an artery and a series of x-rays is taken of arteries that are leading to the kidney. The dye coats the blood vessels, making it easier to see abnormalities on the x-ray images. This test is useful in diagnosing renal cancers and can help in identifying arteries, which will help the surgeon during surgical treatment. This test is rarely used now, though.
    MRI scan —This test uses magnetic waves to produce images of the inside of the body. Using a large magnet, radio waves, and a computer, an MRI produces 2D and 3D pictures.
    Renal ultrasound —This involves the use of sound waves and the characteristic patterns they make bouncing off of various structures in the body to identify tumors and other conditions.
    Biopsy —A biopsy is the removal of a sample of kidney tissue to test for cancer cells. This test is rarely needed, since imaging studies usually provide enough information. When a biopsy is done, the doctor inserts a needle through the skin to remove a sample of tissue from the tumor. This tissue is checked for cancer cells.

    Cytology

    Cytology is the study of cells. The cytology of cancer cells differs significantly from normal cells, and physicians use the unique cellular features seen on biopsy samples to determine the diagnosis and assess the prognosis of a cancer.

    Staging

    Staging is the process by which physicians determine the prognosis of a cancer that has already been diagnosed. Staging is essential for making treatment decisions (eg, surgery vs. chemotherapy ). Several features of the cancer are used to arrive at a staging classification, the most common being the size of the original tumor, extent of local invasion, and spread to distant sites (metastasis). Low staging classifications (0-1) imply a favorable prognosis, whereas high staging classifications (4-5) imply an unfavorable prognosis.
    Additional tests to determine staging may include:
    Blood tests —Blood tests may help determine possible cancer spread to other parts of the body and assess your overall health.
    CT scan —A series of x-rays are put together by a computer to create images of internal areas where the cancer may have spread.
    MRI scan —This test is used to help assess whether the cancer has spread.
    Bone scan —For this test, an injection of a radioactive compound called technetium is given. Three hours later, you lie on a table as special cameras move slowly above and below the table taking pictures. These cameras detect small amounts of radioactivity in the injected technetium, allowing the doctor to see areas of the bone that may contain cancer cells.
    Stages of Kidney Cancer
    Renal cell carcinoma staging considers three categories: tumor, lymph nodes, and metastases (TNM).
    Your doctor considers the following factors to determine the stage of renal cell carcinoma:
    • The size of the tumor and if it has spread to fatty or connective tissue surrounding the kidney
    • Whether the disease has spread to your lymph nodes
    • Whether the disease has spread to the bone, liver, or other places outside the kidney
    Specific TNM classifications
    Kidney Cancer Tumor (T) Stages:
    • TX —Primary tumor cannot be assessed (information not available).
    • T0 —There is no evidence of a primary tumor.
    • T1a —Tumor is 4 cm in diameter or smaller and is limited to the kidney.
    • T1b —Tumor is larger than 4 cm but smaller than 7 cm and is limited to the kidney.
    • T2 —Tumor is larger than 7 cm but is still limited to the kidney.
    • T3a —Tumor has spread into the adrenal gland or into fatty tissue around the kidney, but not beyond a fibrous tissue called Gerota fascia, which surrounds the kidney and nearby fatty tissue.
    • T3b —Tumor has spread into the large vein leading out of the kidney (renal vein) and/or the part of the large vein leading into the heart (vena cava) that is within the abdomen.
    • T3c —Tumor has reached the part of the vena cava that is within the chest or invades the wall of the vena cava.
    • T4 —Tumor has spread beyond Gerota fascia (fibrous tissue that surrounds the kidney and the fatty tissue next to the kidney).

    Kidney Cancer Node (N) Stages:
    • Stage NX —The lymph nodes near the kidneys cannot be assessed.
    • Stage NO —The cancer has not spread to the lymph nodes.
    • Stage N1 —The cancer has spread to one lymph node near the kidney.
    • Stage N2 —The cancer has spread to more than one lymph node near the kidney.

    Kidney Cancer Metastatic (M) Stages:
    • Stage MX —It cannot be assessed if the cancer has spread to distant organs.
    • Stage MO —The cancer has not spread.
    • Stage M1 —The cancer has spread to other parts of the body beyond the kidney area.
    Overall Cancer Stage Based on the American Joint Committee on Cancer (AJCC)
    Stage I —T1a-T1b, N0, M0
    • The tumor is 7 cm or smaller and limited to the kidney.
    • There is no spread to lymph nodes or distant organs.
    Stage II —T2, N0, M0
    • The tumor is larger than 7 cm but is still limited to the kidney.
    • There is no spread to lymph nodes or distant organs.
    Stage III —T1a-T3b, N1, M0 or T3a-T3c, N0, M0
    • There are several combinations of T and N categories that are included in this stage.
    • These include any tumor that has spread to one nearby lymph node, but not to more than one lymph node or other organs.
    • Stage III also includes tumors that have not spread to lymph nodes or distant organs but have spread to the adrenal glands, to fatty tissue around the kidney, and/or have grown into the large vein (vena cava) leading from the kidney to the heart.
    Stage IV —T4, N0-N1, M0 or Any T, N2, M0 or Any T, Any N, M1
    • There are several combinations of T, N, and M categories that are included in this stage.
    Overall Stage T Stage N Stage M Stage
    Stage I T1a-T1b N0 M0
    Stage II T2 N0 M0
    Stage III T1a-T1b or T2 N1 M0
    T3a N0 or N1 M0
    T3b N0 or N1 M0
    T3c N0 or N1 M0
    Stage IV T4 N0 M0
    T4 N1 M0
    Any T N2 M0
    Any T Any N M1

    Prognosis

    Prognosis is a forecast of the probable course and/or outcome of a disease or condition. Prognosis is most often expressed as the percentage of patients who are expected to survive over five or ten years. Cancer prognosis is a notoriously inexact process. This is because the predictions are based on the experience of large groups of patients suffering from cancers at various stages. Using this information to predict the future of an individual patient is always imperfect and often flawed, but it is the only method available.
    The five-year survival rate for all renal cell cancers is 60%. The five-year survival rate by stage is as follows:
    Stage I: 90% to 100%
    Stage II: 65% to 75%
    Stage III: varies widely between 45% and 80%; survival goes down to 15% to 50% if the cancer has spread to other areas, like the renal vein or the regional lymph nodes
    Stage IV: less than 10%
    There are certain risk factors that affect the five-year survival rate. These factors can shorten a patient’s survival time:
      Abnormal blood counts:
      • Lactate dehydrogenase (LDH)—high levels
      • Calcium—high levels
      • Low red blood cell count or anemia
    • Cancer that has spread to two or more distant sites
    • Less than one year from diagnosis to the need for systemic treatment
    • Decreased ability to participate in normal daily activities

    References

    American Cancer Society website. Available at: http://www.cancer.org/docroot/home/index.asp?level=0 .

    Bast R, Kufe D, Pollock R, et al, eds. Cancer Medicine. 5th ed. Hamilton, Ontario: BC Decker Inc; 2000.

    Cashen A, Wildes T. The Washington Manual: Hematology and Oncology Subspeciality Consult. 2nd ed. Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2008.

    How is kidney cancer staged? American Cancer Society website. Available at: http://www.cancer.org/docroot/CRI/content/CRI%5F2%5F4%5F3X%5FHow%5Fis%5Fkidney%5Fcancer%5Fstaged%5F22.asp . Accessed December 14, 2009.

    Kidney Cancer Association website. Available at: http://www.kidneycancerassociation.org/ .

    Maclure M. Asbestos and renal cell carcinoma: a case-control study. Environ Res. 1987;42:353.

    Mandel JS, McLauglin JK, Schlegofer B, et al. International renal cell cancer study. Int J Cancer. 1995;61:601.

    McLauglin JK, Blot WJ, Mehl ES, et al. Petroleum-related employment and renal cell cancer. J Occup Med. 1985;27:672

    National Cancer Institute website. Available at: http://www.cancer.gov/ .

    Pischon, T, Lahmann, PH, Boeing, H, et al. Body size and risk of renal cell carcinoma in the European Prospective Investigation into Cancer and Nutrition (EPIC). Int J Cancer. 2006;118:728

    Rakel R. Bope E, ed. Conn's Current Therapy. 54th ed. St. Louis, MO: WB Saunders; 2002: 721-722.

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