Renal Cancer Diagnosis | MIMS Malaysia

Diagnosis

Staging

Robson staging system

Designed to correlate stage at presentation w/ prognosis & is as follows:

Stage I	Tumor is confined w/in the capsule of the kidney
Stage II	Tumor invades the perinephric fat but is still contained w/in the Gerota’s fascia
Stage III	Tumor invades the renal vein or inferior vena cava, regional lymph node involvement, or both
Stage IV	Tumor invades the adjacent viscera (excluding ipsilateral adrenal) or distant metastases

TNM Classification

Based on the 2010 American Joint Committee on Cancer (AJCC) TNM Staging System for Kidney Cancer

Primary Tumor (T)

TX	Primary tumor cannot be assessed
T0	No evidence of primary tumor
T1	The tumor size is ≤7 cm & is limited to the kidney
T1a	The tumor size is ≤4 cm & is limited to the kidney
T1b	The tumor size is >4 cm but not >7 cm & is limited to the kidney
T2	The tumor size is >7 cm & is limited to the kidney
T2a	The tumor size is >7 cm but is ≤10 cm & is limited to the kidney
T2b	The tumor size is >10 cm & is limited to the kidney
T3	Tumor extends into major veins or perinephric tissues but not into the ipsilateral adrenal gland & not beyond Gerota’s fascia
T3a	Tumor extends into the renal vein or its segmental (muscle containing) branches, or the tumor invades the perirenal &/or renal sinus fat (peri-pelvic) but not beyond the Gerota’s fascia
T3b	Tumor extends into the vena cava below the diaphragm
T3c	Tumor extends into the vena cava above the diaphragm or invades the wall of the vena cava
T4	Tumor invades beyond the Gerota’s fascia (including contiguous extension into the ipsilateral adrenal gland

Regional Lymph Nodes (N)

NX	Regional lymph nodes cannot be assessed
N0	No regional lymph node metastasis
N1	Tumor has metastasized in the regional lymph node

Distant Metastasis (M)

M0	Clinically no distant metastasis
M1	Clinically distant metastasis

Clinical Staging

Based on the 2010 American Joint Committee on Cancer Anatomic Stage & Prognostic Groups

Stage I	T1	N0	M0
Stage II	T2	N0	M0
Stage III	T1 or T2	N1	M0
	T3	N0 or N1	M0
Stage IV	T4	Any N	M0
	Any T	Any N	M1

Assessment

Anatomic Classification Systems

The Preoperative Aspects, Dimensions Used for an Anatomical (PADUA) classification system, R.E.N.A.L. nephrometry score & the C-index are used to standardized the description of renal tumors
These includes assessment of the tumor size, exophytic/endophytic properties, nearness in the collecting system, renal sinus & in the anterior &/or posterior location

History

A detailed history should be elicited
Thorough review of medical records should include:
- Number & frequency of episodes of symptoms
- Previous imaging studies, interventions, evaluations & treatments
Family history w/ 1st or 2nd degree relative
It may also be appropriate to ask for the sexual & psychosexual history of the patient

Physical Examination

Since most of the patients presents w/ metastatic disease, physical examination of the lungs, bone, liver, cutaneous sites & central nervous system should be thoroughly evaluated
Check for hypertension, supraclavicular adenopathy & flank or abdominal mass w/ bruit
Presence of varicocele & paraneoplastic syndromes (eg hypercalcemia, erythrocytosis & Stauffer syndrome) should raise suspicion
If patients presents w/ gross hematuria w/ vermiform clots, consider upper urinary tract bleeding

Imaging

Essential for evaluating & staging renal masses, as well as for therapeutic planning

Bone Scan

Only indicated in patients w/ bone pain &/or an elevated serum alkaline phosphatase

Computed Tomography (CT) Scan

Can differentiate cystic masses from solid masses
Supplies information about the lymph node, renal vein & inferior vena cava involvement
Main modality for the assessment of renal masses, w/ pre- & post-contrast enhanced scanning of the abdomen, pelvis & chest
Abdominal CT scan primarily determines the extent of local & regional involvement
Chest CT scan evaluates the presence of pulmonary or mediastinal lymph node metastases

Intravenous Pyelogram (IVP)

Series of x-rays of the kidneys, ureters & bladder are taken to find out if cancer is present in these organs

Magnetic Resonance Imaging (MRI) Scan

Used to evaluate the inferior vena cava & right atrium for tumor involvement
Helpful in cases of renal insufficiency or contrast allergy preventing the use of IV contrast
May also be used in the assessment of inferior vena cava (IVC) thrombus or on clarifying the anatomy of individual renal lesions

Percutaneous Biopsy

Used in the evaluation of potentially malignant cystic renal lesions detected by ultrasound or CT scan
May also be used for small renal masses if there is a high index of suspicion for a metastatic lesion to the kidney, lymphoma or a focal kidney infection

Positron Emission Tomography (PET) Scan

Evaluation of lymph node involvement & to measure the area of metastasis
Has high sensitivity & specificity for primary lesion

Ultrasonography (UTZ)

Initially detects renal tumors & distinguishes a simple benign cyst from a complex cyst or a solid tumor
Detection of tumors depends on the size, location & echogenecity of the lesion

Laboratory Tests

Complete blood cell (CBC) w/ differential
Electrolytes
Liver function tests (ALT & AST)
Renal profile
Urinalysis
Urine cytology or uteroscopy

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