Sandy Liu, MD, reviews the initial diagnosis and staging of renal cell carcinoma, or kidney cancer, as well as what she discusses with patients who are first presenting with this disease.
PUBLISHED June 18, 2018
Sandy Liu, MD: The overall prevalence of RCC (renal cell carcinoma), or kidney cancer, is actually increasing because now, as patients get older and they go to the emergency room for a simple complaint such as abdominal pain, they get a scan and find these small renal masses. The incidence is actually increasing. However, patients who are diagnosed with later-stage and advanced disease are still pretty much at the same incidence, about 30%. Most of the common symptoms that patients complain of for kidney cancer are usually just some vague abdominal pain. When it does infiltrate the renal pelvis of the kidneys, that’s when patients notice blood in their urine, and that is another common finding of kidney cancer. Sometimes, when the tumor gets really big, they can complain of back pain or something related to the tumor pressing on an organ. Pain is another big issue.
In kidney cancer, the risks come in 2 categories. One category is familial, which is about 2% to 3%, and the most common category is nonfamilial. The nonfamilial causes of kidney cancer are usually related to smoking. There is a direct link for smoking and kidney cancer, and gender also plays a role. Males are about 2 to 3 times more likely to get kidney cancer than females. The other cause is occupational exposures, obesity and sometimes diabetes that can lead to chronic kidney dialysis. That can also have a prevalence in kidney cancer.
Unfortunately, it’s really hard to pick up on kidney cancer, because it’s not something that can be picked up through a screening test, like a blood test, that we commonly find. The most important thing is to change lifestyle. So, if you are a smoker, quit smoking, because that’s the best thing you can do for yourself. If you have a family history, make sure you get screened more often. If you have vague abdominal pain, make sure you go to your primary care physician and get that checked out. But the most important thing is cutting your risk factors.
The standard diagnostic workup for kidney cancer, once it is diagnosed — and this is usually seen on imaging, either an MRI or a CT scan, where they find a small kidney mass — is patients go to see a urologist. Typically, we do not do a kidney biopsy. If it looks suspicious on imaging, we typically remove either part of the kidney or all of the kidney, depending on the size. After the surgery, we can determine the histology of the kidney cancer and move forward with treatment.
Kidney cancer is categorized by stages: stage 1, 2, 3, and 4. If one is diagnosed with stage 1 to stage 3, the curative treatment is surgery. After they have surgery, they receive routine monitoring to make sure that the kidney cancer doesn’t come back. If they do have stage 3 kidney cancer and they are considered high risk, they come to us, and we talk to them about the risk-benefit of starting a pill to prevent the cancer from coming back. However, if they’re diagnosed with stage 4 kidney cancer, which is metastatic disease that spread beyond the kidney, we do still recommend removing the primary kidney, as studies have shown that it does have a survival benefit. Patients generally get better. However, they need something on top of the surgery, which is now systemic therapy. That’s when I come and talk to them about more advanced therapies.
Patients can receive a lot of things. The most common questions I hear are: “How did I get this? How can I prevent this? Can I pass this on to my children?” The most common answer is no, you did not do anything to get this. Maybe this just happened by chance, by some random mutation. We now know a lot of mutations that can occur within kidney cancer, and the most common mutation that’s found is the VHL mutation, which leads to upregulation of hypoxia-inducible factors that cause blood vessel formation and angiogenesis. In terms of how did patients get this, it’s just sometimes by chance. They often ask about prognosis: “How long do I have to live? What are the treatment options? What are the side effects that come with it?” We discuss all that with them in the clinic.