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Diagnosing kidney cancer

Thursday 30 September, 2010

Reviewed by: Associate Professor Ian Davis, MB BS (Hons) PhD FRACP FAChPM
Medical Oncologist, Austin Health, Assoc. Member, Ludwig Institute for Cancer Research

Most kidney cancers are found when a doctor is checking for something else. Kidney cancer often does not produce symptoms in its early stages or sometimes even when it's more advanced.

When they occur, symptoms of kidney cancer can include:

blood in the urine (haematuria)
pain or a dull ache in the side or lower back that is not due to an injury
a lump in the abdomen
constant tiredness
rapid, unexplained weight loss
fever not caused by a cold or flu.

Most of these symptoms can be caused by other illnesses. However, if you have any of these symptoms, you must see your doctor.

Doctors and other health professionals you may see

Your doctor will examine you and refer you for tests to see if you have cancer. This can be a worrying and tiring time, especially if you need to have several tests.

If the tests show you have or may have cancer, your doctor will refer you to a specialist, who will examine you and may ask you to have some more tests. If you have cancer, one or more specialists will advise you about treatment options.

You should expect to be cared for by a team of health professionals from the relevant major fields listed below. Ideally, all tests and treatment should be available at your hospital but this may not be possible.

Specialists and other health professionals who care for people with kidney cancer include:

urologists, who specialise in diseases of and surgery to the urinary system
medical oncologists, who specialise in chemotherapy and other medical treatments
radiation oncologists, who specialise in radiotherapy
nurses and general practitioners, who will help you through all stages of your cancer
dieticians, who will recommend the best diets to follow during and after treatment
social workers, psychologists, counsellors, physiotherapists and occupational therapists, who will advise you on support services and help you to get back to normal activities.

How kidney cancer is diagnosed

This section lists tests that can be helpful in diagnosing kidney cancer. You are unlikely to need all of these tests. You may have had some of them already. Some tests, like bone scans and chest x-rays, are usually only used to help find out if the cancer has spread (metastasised) to other parts of the body.

Ultrasound scan

In this test, sound waves are used to create a picture of your kidneys and the area around your kidneys.

Before your test you may be asked to drink plenty of fluids so that your bladder is full and a clear picture can be seen. Once you are lying comfortably on your back, a gel will be spread over your abdomen.

A small device called a transducer will be passed over the area. It makes sound waves and receives echoes. A computer makes a picture of the echoes produced when the sound waves meet something dense, like an organ or tumour.

An ultrasound scan can show if a cancer is present, and how large it is.

This test is painless and takes about 15 to 20 minutes.

Urine test

You may have a urine test to look for blood and signs of infection in your urine. If there is a cancer, a urine test can also sometimes find cancer cells from the kidney, ureter or bladder, although this is not common.

Blood tests

The doctor will ask for a blood sample to check your general health and blood count (the number of different blood cells in your blood). Too few or too many red blood cells can be a sign of kidney cancer. High levels of liver enzymes and changes in the chemicals and salts in the blood (such as calcium levels) can also be found in people with kidney cancer.

Cystoscopy

If you have blood in your urine, your doctor may want to look directly inside your bladder. This is because the bladder is part of the same body system as your kidneys. This procedure is called a cystoscopy. If an ultrasound has shown a tumour on your kidney, you won't need a cystoscopy.

The cystoscopy is done by a urologist. In many cases, it is done under local anaesthetic. The test is carried out using a small telescope called a cystoscope. This is gently passed through the urethra and into the bladder. Through the cystoscope, the doctor can examine the urethra and bladder. It may be possible to see where the bleeding is coming from.

Intravenous pyelogram (IVP)

This type of x-ray shows up abnormalities in the kidneys, bladder and the rest of the urinary system. IVP is rarely used to diagnose kidney cancer, especially if you have already had a CT scan.

If you need an IVP, dye will be injected into a vein, usually in your arm. The dye travels through the bloodstream into your kidneys and then into your ureters and bladder.

The doctor can watch the dye move through the urinary system on an x-ray screen. The test can detect anything that isn't normal, like a tumour, or kidney damage caused by a tumour.

The dye will probably make you feel hot and flushed for a few minutes, but this feeling will disappear. You may feel some discomfort in your abdomen, but this will only be for a short time. A belt will probably be placed over your lower abdomen and tightened towards the end of the test. This is done to show if there are any problems with the way your bladder empties.

There is a small chance of the injected dye causing an allergic reaction.

You should be able to go home as soon as the test is over. An IVP usually takes about an hour.

Further tests

If tests show you have kidney cancer, your doctor may want to do further tests. These tests are to:

see if the cancer has spread
decide on the best treatment.

Computerised tomography (CT) scan

A CT scan is a type of x-ray that takes many pictures of your organs and other structures, including the kidneys. These are put together to build up a three-dimensional picture of your body.

CT scans are usually done at a hospital or a radiology clinic. It takes about 30 to 40 minutes to complete this painless test.

You may be asked to not eat or drink for four hours before the scan. However, you will be asked to drink and have an injection of a liquid dye. This helps outline the kidneys, ureters and bladder. You will be asked to lie on a table that slowly moves through the CT scanner, which is large and round like a doughnut. Most people are able to go home as soon as their scan is over.

There is a small possibility of the injected dye causing an allergic reaction. You should tell your doctor if you are allergic to iodine or to contrast dyes, or if you are diabetic or have abnormal kidney function.

Chest x-ray

A chest x-ray uses low doses of radiation to check for abnormal areas in the chest. It takes only a few minutes and is painless and safe. If cancer has been diagnosed, a chest x-ray can show whether cancer has spread to your lungs or to the bones in your chest.

Magnetic resonance imaging (MRI)

This test is like a CT scan, but it uses magnetism instead of x-rays to build up pictures of your body. It may be able to provide more details than a CT scan. However, only a small percentage of people with kidney cancer need this test. You may have an MRI if your doctor has concerns the cancer has:

gone into the renal vein
spread to your spinal cord.

Like a CT scan, MRI is painless, and the magnetism is harmless. You will be asked to lie still on a table inside a large metal tube, which is open at both ends. The tube makes some people feel claustrophobic (afraid of being in a small space). If you think you are likely to feel this way, please tell the treatment centre in advance: you may be able to take someone into the room with you for support. The machine can be quite noisy.

Because the scanner uses a powerful magnet, if you have a pacemaker or other metal objects in your body, it may not be safe to have an MRI scan. Speak to your doctor or the staff at the MRI scanner if you are not sure.

There is a small possibility of the injected dye causing an allergic reaction. You should tell your doctor if you have abnormal kidney function.

The test may take up to an hour.

Bone (radioisotope) scan

This test is not commonly used for people with kidney cancer. You may need a bone scan if:

you have symptoms to suggest the cancer has spread to the bones (e.g. bone pain)
your doctor needs to evaluate a very large or advanced kidney cancer

Your doctor needs to assess how well you are responding to treatments sometimes given for advanced kidney cancer (e.g. Sunitinib).

A radioisotope scan can look for cancer cells that may have spread beyond the kidney and into other places such as the bones. You will have a small amount of a radioactive substance injected into a vein, usually in your arm.

It is normal to wait for the dye to move through the body for a while before the images are taken. For a bone scan, this can take three to four hours. You will be scanned by a machine which detects tiny amounts of radioactivity.

The doctor can tell if the cancer has spread, as a larger amount of radioactivity is found in areas of bone affected by cancer cells. This causes a dark spot to appear on the bone scan. The scan is also used to see if your other kidney is healthy.

The amount of radiation used is small, and the radiation disappears from your body within a few hours. You will be advised to avoid contact with pregnant women and young children for the rest of the day, and drink plenty of fluids.

This procedure is not recommended for pregnant or breastfeeding women.

Biopsy

A biopsy means taking a small piece of your kidney tissue for special tests. Biopsy is rarely used to diagnose kidney tumours. Other tests usually tell the doctor enough to make decisions about treatment. However, your doctor may suggest you have a kidney biopsy:

if the tumour is small and other tests were unable to show if the tumour was cancerous (malignant) or non-cancerous (benign)
to confirm a cancer diagnosis in someone who has poor health, for whom surgery is not an option.

If your doctor suggests you have a biopsy they will discuss in detail with you what this means. You may like to ask your doctor why you need the test and what risks are involved.

After the tests

Your test results may take a little time. It is usually only a few days. It is natural to feel very anxious while you are waiting. During this time it can help to discuss your feelings with someone such as a close friend or relative. You can also speak to a cancer nurse on the Cancer Council Helpline - call 13 11 20. They can put you in touch with others who have been through a similar experience.

‘Staging' the disease

The tests described on previous pages show whether you have cancer. If you have cancer, the tests will show where the primary cancer is. If the cancer has spread, the tests may show where the cancer cells have spread to other parts of your body. This helps your doctors ‘stage' the disease so they can work out the best treatment for you.

The staging system used for kidney cancer is known as the ‘TNM system' (T = tumour, N = nodes, M = metastases).

T followed by a number between 1 and 4 describes how far the cancer has spread into the kidney and nearby tissues. A higher number after the T (e.g. T3 or T4) means it has spread through the kidney into nearby tissues.
N plus a number from 0 to 2 describes whether the cancer has spread to lymph nodes near the kidney. Higher numbers are used when more than one group of nodes is affected by the cancer.

M followed by 1 shows that the cancer has spread to other organs or to lymph nodes that are not near the kidney. M0 cancers have not spread in this way.

Doctors combine this information to work out the stage of the cancer, from Stage 1 to Stage 4. For example, a cancer assessed as T1, N0, M0 (tumour contained within the kidney, lymph nodes not affected and no metastasis) would be called a Stage 1 cancer.

Ask your doctor to explain the stage of your cancer in a way you can understand. This will help you to choose the best treatment for your situation.

Your doctor may mention the ‘grade' of your cancer. This refers to its appearance under the microscope. A lower grade, for example, a Grade 1 cancer, is slower growing and less likely to spread. However, the grade of the cancer is not necessarily a very good predictor of how it will behave.

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Updated: 30 Sep, 2010