SCREENING & DIAGNOSIS

Renal cell carcinomas can become quite large without causing any symptoms. At the present time, there is no specific blood test for renal cell carcinoma. Patients with a family history (multiple family members) should be followed more closely. In most cases, renal cell carcinoma is found when hematuria or blood in the urine is seen. This is the most common symptom. Many tumors are found incidentally when a procedure or radiological study is done for vague symptoms. Other signs and symptoms that may prompt consultation with a doctor include not only hernaturia but also persistent low back pain, a mass in the abdomen, fatigue, weight loss, fever not obviously associated with infection and swelling of the legs. Often these symptoms are associated with other causes that are not due to cancer but still deserve evaluation. If the tumor is diagnosed early then the vast majority of patients (80 to 100%) are cured. Incidental renal cell carcinomas have the most favorable prognosis or outlook.

1. Physical Examination - a complete history and physical examination helps evaluate the entire patient.

2. Urinalysis is performed to microscopically look at the urine to verify there is blood in it. Sometimes urine cytologies are sent which are used to look for cancer cells in the urine. Many other blood tests can be done to evaluate the function of the kidney, liver and other organs.

3. There are multiple imaging studies, including intravenous pyelogram (IVP), ultra-sonography, computerized tomographic (CT) scans, magnetic resonance imaging (MRI) which can produce images of the kidney.
   

   A CT scan is a modified x-ray procedure which produces a detailed picture of the inside of the body. MRI uses large magnets to produce images of the internal organs. Utrasonography uses sound waves that show the kidney, like one uses sonar to took for a submarine. Arteriography and angiography are older studies which are still used that employ contrast dyes to demonstrate blood vessels and image the kidney. A chest x-ray is used to evaluate the lungs to see if there is any metastases or spread of cancer. A bone scan uses small amounts of special radioactive tracer material that can identify cancer in bones.

4. Cystoscopy is sometimes performed to verify that there are no tumors in the bladder, and also whether there is bleeding from one or both kidneys.

Staging is a process that defines the full extent of the cancer. In general, the staging process is approached by an assessment of the tumor extent, nodal extent and metastatic spread.  It is referred to as the TNM system, and is the approved method of assessment by the American Joint Committee on Cancer staging (AJCC).  Once a TNM stage is determined the overall clinical stage is defined.  The TNM system is outlined below:

T Categories for Kidney Cancer
TX: The primary tumor cannot be assessed (information not available).
T0: No evidence of a primary tumor.
T1: The tumor is only in the kidney and is 7 cm (a little less than 3 inches) or less across

• T1a: The tumor is 4 cm (about 11/2 inches) across or smaller and is only in the kidney.
• T1b: The tumor is larger than 4 cm but not larger than 7 cm across and is only in the kidney.

T2: The tumor is larger than 7 cm across but is still only in the kidney.

• T2a: The tumor is more than 7 cm but not more than 10 cm (about 4 inches) across and is only in the kidney
• T2b: The tumor is more than 10 cm across and is only in the kidney

T3: The tumor is growing into a major vein or into tissue around the kidney, but it is not growing into the adrenal gland (on top of the kidney) or beyond Gerota's fascia (the fibrous layer that surrounds the kidney and nearby fatty tissue).

• T3a: The tumor is growing into the main vein leading out of the kidney (renal vein) or into fatty tissue around the kidney
• T3b: The tumor is growing into the part of the large vein leading into the heart (vena cava) that is within the abdomen.
• T3c: The tumor has grown into the part of the vena cava that is within the chest or it is growing into the wall of that blood vessel (the vena cava).

T4: The tumor has spread beyond Gerota's fascia (fibrous layer that surrounds the kidney and nearby fatty tissue). The tumor may have grown into the adrenal gland (on top of the kidney).

N Categories for Kidney Cancer
NX: Regional (nearby) lymph nodes cannot be assessed (information not available).
N0: No spread to nearby lymph nodes.
N1: Tumor has spread to nearby lymph nodes.

M Categories for Kidney Cancer
M0: There is no spread to distant lymph nodes or other organs.
M1: Distant metastasis is present; includes spread to distant lymph nodes and/or to other organs (such as the lungs, bones, or brain).

Stage Grouping
Once the T, N, and M categories have been assigned, this information is combined to assign an overall stage of I, II, III, or IV. The stages identify cancers that have a similar prognosis and thus are treated in a similar way. Patients with lower stage numbers tend to have a better prognosis.

Stage I: T1, N0, M0
The tumor is 7 cm across or smaller and is only in the kidney (T1). There is no spread to lymph nodes (N0) or distant organs (M0).

Stage II: T2, N0, M0
The tumor is larger than 7 cm across but is still only in the kidney (T2). There is no spread to lymph nodes (N0) or distant organs (M0).

Stage III: Either of the following:
T3, N0, M0: The tumor is growing into a major vein (like the renal vein or the vena cava) or into tissue around the kidney, but it is not growing into the adrenal gland or beyond Gerota's fascia (T3). There is no spread to lymph nodes (N0) or distant organs (M0).
T1 to T3, N1, M0: The main tumor can be any size and may be outside the kidney, but it has not spread beyond Gerota's fascia. The cancer has spread to nearby lymph nodes (N1) but has not spread to distant lymph nodes or other organs (M0).

Stage IV: Either of the following:
T4, any N, M0: The main tumor is growing beyond Gerota's fascia and may be growing into the adrenal gland on top of the kidney (T4). It may or may not have spread to nearby lymph nodes (any N). It has not spread to distant lymph nodes or other organs (M0).
Any T, Any N, M1: The main tumor can be any size and may have grown outside the kidney (any T). It may or may not have spread to nearby lymph nodes (any N). It has spread to distant lymph nodes and/or other organs (M1).