Renal%20cancer Diagnosis

Robson Staging System

• Designed to correlate stage at presentation with prognosis and is as follows:

  Stage I	Tumor is confined within the capsule of the kidney
  Stage II	Tumor invades the perinephric fat but is still contained within 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 2017 American Joint Committee on Cancer (AJCC) TNM staging system for kidney cancer

Primary Tumor (T)

Regional Lymph Nodes (N)

Clinical Staging

• Based on the 2017 AJCC anatomic stage and prognostic groups



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

• Management depends upon the disease's TNM classification, histologic subtype, and prognosis

• Most widely used prognostic factor model
• Prognostic factors include the following:
  • <1 year interval from diagnosis to treatment initiation
  • Karnofsky performance status of <80%
  • >1.5 x upper limit of normal (ULN) serum lactate dehydrogenase (LDH)
  • Corrected serum calcium > ULN
  • Serum hemoglobin (Hgb) less than lower limit of normal (LLN)
• Based on above prognostic factors, identify the patient's prognostic risk group using the following parameters:
  • Low-risk: Prognostic factors absent
  • Intermediate-risk: 1-2 prognostic factors present
  • Poor-risk: ≥3 prognostic factors present

• Presence of ≥3 of the following represents the poor-prognosis group:
  • LDH of >1.5 x ULN
  • Hgb < LLN
  • Corrected serum calcium > 10 mg/dL (2.5 mmol/L)
  • <1 year interval from diagnosis to initiation of systemic therapy
  • Karnofsky performance score ≤70
  • ≥2 sites of metastasis

• Derived from a study composed of patients with metastatic renal cancer given vascular endothelial growth factor(VEGF)-targeted therapy
• Prognostic factors include the following:
  • <1 year interval from diagnosis to initiation of systemic therapy
  • Karnofsky performance status of <80%
  • Serum Hgb <120 g/L or 12 g/dL
  • Serum calcium >10.2 mg/dL
  • Neutrophil count >7.0 x 10⁹/L
  • Platelet count >400,000
• Based on above prognostic factors, identify the patient's prognostic risk group using the following parameters:
  • Favorable-risk: Prognostic factors absent
  • Intermediate-risk: 1-2 prognostic factors present
  • Poor-risk: 3-6 prognostic factors present

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

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

• Essential for evaluating and staging renal masses, as well as for therapeutic planning

Bone Scan

• Only indicated in patients with bone pain and/or an elevated serum alkaline phosphatase

Chest X-ray

• An essential part of patient's initial work-up

Computed Tomography (CT) Scan

• Can differentiate cystic masses from solid masses
• Supplies information about the lymph node, renal vein and inferior vena cava involvement
• Main modality for the assessment of renal masses, with pre- and post-contrast enhanced scanning of the abdomen, pelvis and chest
• Abdominal CT scan primarily determines the extent of local and 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 and 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 and 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
• May be considered when a central renal mass is present suggestive of urothelial carcinoma if with metastatic disease or if patient cannot tolerate ureteroscopy

Positron Emission Tomography (PET) Scan

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

Ultrasonography

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

Ureteroscopy

• May consider when a central renal mass is present and suggestive of urothelial carcinoma

• Complete blood cell (CBC) with differential
• Electrolytes
• Serum lactate dehydrogenase (LDH)
• Liver function tests [alanine aminotransferase (ALT) and aspartate aminotransferase (AST)]
• Renal profile
• Serum corrected calcium
• Urinalysis
• Urine cytology or uteroscopy
• Genetic evaluation (for patients with multiple tumors or <46 years of age)

• The Preoperative Aspects, Dimensions Used for an Anatomical (PADUA) classification system, R.E.N.A.L. nephrometry score and 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 and in the anterior and/or posterior location

• Based on the World Health Organization classification of 2016
• More pertinent segregation is based whether the tumor histological subtype belongs to clear cell or non-clear cell

• Clear cell RCC (ccRCC)
• Clear cell papillary RCC

• Multilocular cystic renal neoplasm of low malignant potential
• Hereditary leiomyomatosis and RCC-associated RCC
• Succinate dehydrogenase-deficient RCC
• Acquired cystic disease-associated RCC
• Papillary RCC
• Chromophobe RCC
• Collecting duct carcinoma
• Renal medullary carcinoma
• MiT family translocation RCC
• Mucinous tubular and spindle cell carcinoma
• Tubulocystic RCC
• Unclassified RCC
• Papillary adenoma
• Oncocytoma

• For patients with confirmed hereditary RCC without radiographic or pathologic diagnosis, the following are recommended:
  • Screening should start 10 years prior to the earliest age at which a family member was diagnosed
  • Abdominal MRI (preferred) or CT scan may be used with and without contrast depending on tumor type:
    • BAP1-tumor predisposition syndrome (BAP1-TPDS): Every 2 years starting at 30 years of age
    • BHDS: Every 3 years starting at 20 years of age
    • HLRCC: Annually starting at 8-10 years of age
    • HPRC: Every 1-2 years starting at 30 years of age
    • PGL/PCC: Every 4-6 years starting at 12 years of age
    • TSC: Every 3-5 years starting at 12 years of age
    • VHL: Every 2 years starting at 15 years of age, to assess the kidneys, pancreas and adrenals
  • Frequency of imaging may be increased once lesions have been detected