Renal Cell Carcinoma Workup

  • Author: Brendan Curti, MD; Chief Editor: Jules E Harris, MD   more...
 
Updated: Mar 2, 2012
 

Approach Considerations

Renal cell carcinoma (RCC) is a unique and challenging tumor because of the frequent occurrence of paraneoplastic syndromes, including hypercalcemia, erythrocytosis, and nonmetastatic hepatic dysfunction (ie, Stauffer syndrome). Thus, laboratory studies in the evaluation of renal cell carcinoma should include a workup for paraneoplastic syndromes.

A large proportion of patients diagnosed with renal cancer have small tumors discovered incidentally on imaging studies. A number of diagnostic modalities are used to evaluate and stage renal masses, including excretory urography, computed tomography (CT) and positron-emission tomography (PET) scanning, ultrasonography, arteriography, venography, and magnetic resonance imaging (MRI).

Determining whether a space-occupying renal mass is benign or malignant can be difficult. Radiologic studies should be tailored to enable further characterization of renal masses, so that nonmalignant tumors can be differentiated from malignant ones.

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Recommended Tests

The following are initial laboratory studies in the evaluation of suspected renal cell carcinoma (RCC):

  • Urine analysis (UA)
  • Complete blood cell (CBC) count with differential
  • Electrolytes
  • Renal profile
  • Liver function tests (LFTs) (aspartate aminotransferase [AST] and alanine aminotransferase [ALT])
  • Calcium
  • Erythrocyte sedimentation rate (ESR)
  • Prothrombin time (PT)
  • Activated partial thromboplastin time (aPTT)

Obtain other tests as indicated by the patient’s presenting symptoms.

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Excretory Urography

Excretory urography is not used frequently in the initial evaluation of renal masses because of its low sensitivity and specificity. A small- to medium-sized tumor may be missed by excretory urography.

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CT Scanning

Contrast-enhanced computed tomography (CT) scanning has become the imaging procedure of choice for diagnosis and staging of renal cell cancer and has virtually replaced excretory urography and renal ultrasonography. In most cases, CT imaging can differentiate cystic masses from solid masses and supplies information about lymph node, renal vein, and inferior vena cava involvement.

The 2009 American Urological Association (AUA) guideline for the management of the clinical T1 renal mass recommends a high-quality cross-sectional CT or MRI, first without and then with intravenous contrast if renal function is adequate. The objective is to rule out angiomyolipoma, evaluate for locally invasive features, study the involved anatomy, and determine status of the uninvolved kidney and its vasculature.[14] The National Comprehensive Cancer Network (NCCN) version 2.2011 guidelines for kidney cancer states that abdominal and pelvic CT with and without contrast and chest CT or radiograph are necessary imaging in initial workup.[15]

A study by Sauk et al concluded that multidetector CT imaging characteristics may aid in identifying differences at the cytogenic level among patient with clear cell renal cell carcinomas.[16]

The NCCN guideline recommends abdominal MRI to assess suspected tumor involvement in the inferior vena cava, or as an alternative to CT for renal mass detection and staging in cases where renal function is inadequate to permit contrast.[15]

Positron-emission tomography (PET) imaging remains controversial in kidney cancer. This technique has a better sensitivity for detecting metastatic lesions than for determining the presence of cancer in the renal primary site.

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Ultrasonography

Ultrasonographic examination can be useful in evaluating questionable cystic renal lesions if computed tomography imaging is inconclusive. Large papillary renal tumors are frequently undetectable by renal ultrasonography.

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Arteriography

Renal arteriography is not used in the evaluation of a suspected renal mass as frequently now as it was in the past. When inferior vena cava involvement is suspected, either inferior venacavography or magnetic resonance angiography (MRA) is used. Magnetic resonance studies are currently the preferred imaging technique. Knowledge of inferior vena cava involvement is important in planning the vascular aspect of the operative procedure.

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Bone Scanning

A bone scan is recommended for patients with bone pain or an elevated alkaline phosphatase level.[15]

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Percutaneous Cyst Puncture

Percutaneous cyst puncture and fluid analysis is used in the evaluation of potentially malignant cystic renal lesions detected by ultrasonography or computed tomography imaging.

According to the 2009 AUA management guideline, a renal mass core biopsy via percutaneous approach, with or without fine needle aspiration, is indicated in patients for whom it might affect approach to treatment, especially in patients with clinical or radiographic evidence of lymphoma, abscess, or metastasis.[14]

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Histology

Renal cell carcinoma (RCC) has 5 histologic subtypes: clear cell (75%), chromophilic (15%), chromophobic (5%), oncocytoma (3%), and collecting duct (2%). Table, below, briefly summarizes characteristics of these 5 subtypes.

Clear cell carcinoma is characterized by unusually clear cells with a cytoplasm rich in lipids and glycogen, and it is most likely to show 3p deletion. Chromophilic tumors tend to be bilateral and multifocal and may have trisomy 7 and/or trisomy 17. Chromophobic carcinoma is characterized by large polygonal cells with pale reticular cytoplasm characterize, and it does not exhibit 3p deletion. Renal oncocytoma consists predominantly of eosinophilic cells, in a characteristic nested or organoid pattern, that rarely metastasize and that do not exhibit 3p deletion or trisomy 7 or 17.

Collecting duct carcinoma is an unusual variant characterized by a very aggressive clinical course. This disease tends to affect younger patients and may present as local or widespread advanced disease. These cells can have 3 different types of growth patterns: acinar, sarcomatoid, and tubulopapillary. The sarcomatoid variant, which can occur with any histologic cell type, is associated with a significantly poorer prognosis.

The following table provides a brief summary of the 5 histologic subtypes of renal cell carcinoma.

Table. Pathologic Classification of Renal Cell Carcinoma (Open Table in a new window)

Cell TypeFeaturesGrowth PatternCell of OriginCytogenetics
Clear cellMost commonAcinar or sarcomatoidProximal tubule3p-
ChromophilicBilateral and multifocalPapillary or sarcomatoidProximal tubule+7, +17, -Y
ChromophobicIndolent courseSolid, tubular, or sarcomatoidCortical collecting ductHypodiploid
OncocyticRarely metastasizeTumor nestsCortical collecting ductUndetermined
Collecting ductVery aggressivePapillary or sarcomatoidMedullary collecting ductUndetermined

Go to Clear Cell Renal Cell Carcinoma and Sarcomatoid and Rhabdoid Renal Cell Carcinoma for complete information on these topics.

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Contributor Information and Disclosures
Author

Brendan Curti, MD  Director, Genitourinary Oncology Research, Robert W Franz Cancer Research Center, Earle A Chiles Research Institute, Providence Cancer Center

Brendan Curti, MD is a member of the following medical societies: American College of Physicians, American Society of Clinical Oncology, Oregon Medical Association, and Society for Biological Therapy

Disclosure: Nothing to disclose.

Coauthor(s)

Bagi RP Jana, MD  Assistant Professor, University of Texas Medical Branch, Galveston, TX

Bagi RP Jana, MD is a member of the following medical societies: American Cancer Society, American Medical Association, American Society of Clinical Oncology, and Southwest Oncology Group

Disclosure: Nothing to disclose.

Mansoor Javeed, MD, FACP  Clinical Assistant Professor of Medicine, University of California, Davis, School of Medicine; Consultant, Sierra Hematology-Oncology Medical Center

Mansoor Javeed, MD, FACP is a member of the following medical societies: American College of Physicians and Pennsylvania Medical Society

Disclosure: Nothing to disclose.

Issam Makhoul, MD  Associate Professor, Department of Medicine, Division of Hematology/Oncology, University of Arkansas for Medical Sciences

Issam Makhoul, MD is a member of the following medical societies: American Society of Clinical Oncology and American Society of Hematology

Disclosure: Nothing to disclose.

Kush Sachdeva, MD  Southern Oncology and Hematology Associates, South Jersey Healthcare, Fox Chase Cancer Center Partner

Disclosure: Nothing to disclose.

Specialty Editor Board

Michael Perry, MD, MS, MACP  Nellie B Smith Chair of Oncology Emeritus, Director, Division of Hematology and Medical Oncology, Deputy Director, Ellis Fischel Cancer Center, University of Missouri-Columbia School of Medicine

Michael Perry, MD, MS, MACP is a member of the following medical societies: Alpha Omega Alpha, American Association for Cancer Research, American College of Physicians, American College of Physicians-American Society of Internal Medicine, American Medical Association, American Society of Clinical Oncology, American Society of Hematology, International Association for the Study of Lung Cancer, and Missouri State Medical Association

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Wendy Hu, MD  Consulting Staff, Department of Hematology/Oncology and Bone Marrow Transplantation, Huntington Memorial Medical Center

Wendy Hu, MD is a member of the following medical societies: American Association for the Advancement of Science, American College of Physicians, American Society for Blood and Marrow Transplantation, American Society of Hematology, and Physicians for Social Responsibility

Disclosure: Nothing to disclose.

Chief Editor

Jules E Harris, MD  Clinical Professor of Medicine, Section of Hematology/Oncology, University of Arizona College of Medicine, Arizona Cancer Center

Jules E Harris, MD is a member of the following medical societies: American Association for Cancer Research, American Association for the Advancement of Science, American Association of Immunologists, American Society of Hematology, and Central Society for Clinical Research

Disclosure: GlobeImmune Salary Consulting

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Table. Pathologic Classification of Renal Cell Carcinoma
Cell TypeFeaturesGrowth PatternCell of OriginCytogenetics
Clear cellMost commonAcinar or sarcomatoidProximal tubule3p-
ChromophilicBilateral and multifocalPapillary or sarcomatoidProximal tubule+7, +17, -Y
ChromophobicIndolent courseSolid, tubular, or sarcomatoidCortical collecting ductHypodiploid
OncocyticRarely metastasizeTumor nestsCortical collecting ductUndetermined
Collecting ductVery aggressivePapillary or sarcomatoidMedullary collecting ductUndetermined
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