Symptoms
Currently there is no effective screening programme or screening test for renal cancer and it is only diagnosed through clinical experience and scanning.
The classic symptoms of renal cancer are haematuria (the appearance of blood in the urine), loin pain and abdominal mass but only 10% of people present with all three of these symptoms together. Back pain, night sweats, polycythaemia (an increase in the concentration of red blood cells), and a left sided varicocele (varicose vein of the scrotum) can also lead to a diagnosis of renal cancer. More than 50% of renal tumours are now detected when using ultrasound for non-specific symptoms such as general abdominal pain, hypertension, malaise, weight loss, anorexia, anaemia, elevated C-reactive protein (CRP: a non-specific blood test that shows the presence of inflammation) or abnormal liver function tests (LFTs).
As the kidney is outside of the peritoneum, a renal tumour has plenty of room to grow before it makes its presence known, unless it bleeds, by which time it can have grown to quite a size, or metastasised. Unfortunately, 25-30% of people with renal cancer present with symptoms of metastatic disease such as a persistent cough, frequent headaches, bone pain, or abnormal liver function tests. Because of the difficulty in identifying renal cancer in the early stages of the disease, 5-year survival rates are approximately 60% for both men and women. With improved imaging techniques, and more frequent use of scans we are seeing an increasing number of renal cancers diagnosed that could be described as incidental.
In the UK, as a result of the NHS Cancer Plan, no patient should wait for more than 62 days from an urgent referral for suspected cancer to the beginning of treatment (National Institute for Health and Care Excellence (NICE) Guidelines for Suspected Cancer: recognition and referral, 2015). This means that GPs can refer ‘fast track’ patients to NHS hospital services to be seen within 2 weeks if they have any clinical suspicion of a renal cancer. All doctors have been given guidelines on what constitutes clinical suspicion for a renal cancer. However, as seen above many symptoms of renal cancer are non-specific and simple reasons for these symptoms need to be ruled out first. This can lead to a delay in diagnosis.
Methods of Diagnosis
As some people with renal cancer present with haematuria they may have a urine test to rule out infection in the first instance. If there is no evidence of infection, or the haematuria continues the person is usually referred to hospital and may have a cystoscopy, renal ultrasound scan and CT urogram. This is to look in more detail to see whether it is a transitional cell carcinoma (TCC; cancer of the bladder, ureter or renal pelvis) or a renal cell carcinoma (RCC) that is causing the bleeding.
Cystoscopy
This involves passing a flexible cystoscope into the bladder, usually under local anaesthetic. The bladder is dilated with saline and the bladder mucosa is checked for any abnormalities.
Renal Ultrasound Scan
Ultrasound imaging is a safe, non-invasive and brief test that can detect renal tumours. This is usually performed in an X-ray department of a hospital, but some GP practices now have access to ultrasound machines. Ultrasound imaging is a scanning technique that uses high-frequency sound waves to create an image of the internal organs of the body on a special computer screen. For this test a transducer (a small microphone-type instrument), is placed on the skin near the kidney. The image is actually formed by echoes of the sound waves on the surface of the organs. Abnormal tissue masses and organs reflect sound waves differently and this is why the ultrasound may be useful in diagnosing renal carcinoma. The echo patterns produced by most renal tumours look different from those of normal kidney tissue. Ultrasound can be helpful in determining if a kidney mass is solid (a tumour) or filled with fluid (a cyst). The ultra-sonographer will examine the kidneys, ureters and the bladder when requested to perform a renal ultrasound.
CT Urogram or Renal CT
Computed tomography (CT) is the gold standard for imaging renal tumours. A CT urogram is a sophisticated imaging technique which uses X-rays to give a more detailed picture of the kidneys, ureters and bladder. An injection of contrast medium is given intravenously, and the patient is then scanned using a CT scanner. This involves lying on table and going through a large donut shaped machine that takes X-rays though the body in slices at a rate of approximately 1 per second. These images are then formatted to show the structures within an area of the body. A renal CT involves performing a scan before injecting the contrast medium, and then performing another one after contrast has been injected. This is not as good for looking at the ureters but is used to identify abnormal lumps on the kidney, and to see if they are solid and have a blood flow through them which is more likely to be a cancer. CT scans can also be used to see if the cancer has spread to other parts of the body.
Other Radiological Investigations
If a CT scan of the chest is not performed a plain chest X-ray may be used to look for lung metastases; this tends to be used less often these days, as CT is more accurate.
If a CT urogram is not performed then an intravenous urogram (IVU) may be used to look at the renal pelvis, ureters and bladder lining. This involves injecting a radioactive medium and taking X-rays of the urinary system.
Positron emission tomography (PET) using a mildly radioactive form of glucose is used to find malignant tumours. Malignant cells take up more glucose than normal cells and therefore ‘light up’ on the PET scan. PET using a radioactive isotope of the CA9 protein, which is specific to cancerous renal cells, can also be used to identify malignant tumours in the kidney.
Magnetic resonance imaging (MRI) is a non-invasive imaging technique that employs a powerful magnetic field, radio frequency pulses and a computer to construct detailed pictures of the inside of the body. The principle of MRI relies on the water content of the body, which makes it particularly useful for imaging tissues such as the brain, muscle, connective tissue and most tumours.
Contrast agents may be injected intravenously to enhance the appearance of blood vessels, tumours or inflammation. Unlike CT, MRI uses no ionizing radiation and is generally a very safe procedure. Nonetheless, the strong magnetic fields and radio pulses can affect metal implants, including cochlear implants and cardiac pacemakers. In the case of cardiac pacemakers, the results can sometimes be lethal, so patients with such implants are generally not eligible for MRI.
Other Tests
Biopsy: This is rarely performed to identify renal cancer. As the non diagnostical rate and negative predictive value of renal mass biopsy is a concern (Patel et al 2016). Further research will determine it’s true clinical utility. Radiological diagnosis is usually sufficient, but if there is any doubt, a biopsy can be carried out under CT or ultrasound guidance under local anaesthetic.
Bone scan: kidney cancer can metastasis to the bone, but metastases would usually be visible elsewhere in the body before the cancer spreads to the bone, therefore, not every patient is required to have one of these. However, if there is a suspicion that there may be spread to the bones this test may be performed. A bone scan involves the injection of a radioactive isotope that travels though the blood and collects in the bones. After a couple of hours, a scan is performed to look for the uptake of the radioactive material. Areas where there is damage to the bone will show up as ‘hot spots’. These aren’t necessarily the result of cancer; arthritis and previously broken bones, for instance, will show up on the scan. However, radiologists can usually differentiate between them and cancerous uptake.
Divided renal function scan (sometimes called a MAG 3 scan): this is a nuclear medicine scan that allows the percentage renal function for each kidney to be calculated. This is especially important if the renal cortex of the unaffected kidney looks dull on a CT scan, or is very small or ragged looking and a nephrectomy is to be carried out. It will help to identify if the remaining kidney has sufficient function to cope with being a solitary kidney.
Impact of Diagnosis and Nursing Care
The devastating impact of a diagnosis of cancer on the patient and their family must never be underestimated. It must be remembered that it is not just the patient who requires support. All patients have different ways of coping with being presented with this type of information and the approach taken by health professionals in addressing these issues must be individualised. Reactions to receiving a diagnosis of renal cancer are similar to other cancers. In the UK, as there has been much in the press over the recent years about unequal access to drugs for renal cancer, patients have become increasingly aware of the lack of curative treatment for metastatic renal cancer. Therefore, many patients will realise immediately the seriousness of their condition. As with other cancers, different reactions are likely to be exhibited, for example, disbelief, anger, denial, panic, anxiety, and helplessness. The nurse needs to be aware of these types of reactions and for all of these patient’s support must be available from the time they obtain their diagnosis. Time needs to be spent examining fears and anxieties that have arisen as a result of the bad news. Most patients and their carers will have very little knowledge of the disease, the staging process and treatments, and will have a number of questions that will need to be answered. They may also have inaccurate preconceived ideas. Listening carefully to the patient will provide information about their understanding of the disease.
Anxiety that is caused by not knowing what to expect is one area that can be addressed by the provision of accurate information in a language that the patient understands. Careful assessment is necessary to be able to decide how much information each individual patient wants and the decision of those who decide they want no information must be respected.
At this stage, perhaps the most important intervention of the nurse is actually being there, allowing the patient time to express their feelings, answering questions honestly, and providing accurate information. Whenever possible, patients must also be provided with information on where to obtain further support or how to gain further information about the disease. The involvement of other members of the multidisciplinary team that may be able to contribute towards the psychological / emotional support of the patient should also be considered at this stage. (Useful sources of support and information for renal cancer patients are introduced in Module 6. Palliative care of renal cancer patients is discussed in Module 5).
References
Patel HD, Johnson MH, Pierorazio PM, Sozio SM, Sharmar R. Iyohae E, Brass EB, Allaf ME (2016) Diagnostic accuracy of risks of biopsy in the diagnosis of an renal mass suspicious for localized Renal cell Carcinoma: Systematic review of literature. Journal of urology 195 (5) p1340-7
National Institute for Health and Care Excellence (NICE): Suspected Cancer: recognition and referral, 2015. https://www.nice.org.uk/guidance/ng12