What Your Renal Cell Carcinoma Diagnosis and Pathology Report Can Reveal

Katherine Banwell: 

Dr. Hall, how is renal cell carcinoma diagnosed and staged?

Dr. Evan Hall: 

Yeah, we’re usually one of two ways in which patients learn they have this problem. One is the presence of symptoms related to the cancer itself. If the symptoms are coming from the tumor in the kidney itself, the most common symptoms are pain in the flank, blood in the urine, and sometimes patients can have night sweats, weight loss, kind of full-body fatigue, full-body systemic symptoms from the cancer itself.

So, in that setting, they usually report those symptoms to a doctor, get tests, and ultimately identify this problem. Another important way that patients are diagnosed is a kidney mass is found incidentally while they’re having testing done for something else. So, it’s not uncommon in my practice that someone goes in to get a different symptom checked out, they end up getting an ultrasound or a CT scan, and there’s a kidney mass identified that probably wasn’t related to the original reason they sought care. So, we would say that sometimes these cancers are diagnosed incidentally or in the absence of a symptom because other tests are being done.

Katherine Banwell: 

How does stage and grade affect treatment choices?

Dr. Evan Hall: 

Yeah, so the staging of the cancer, just to elaborate a bit on that, the first thing that typically happens is patients have imaging.

And we really get a sense of how large is the tumor, what part of the kidney is affected, and then importantly, are there areas of concern for cancer beyond the kidney itself? Does it appear that the cancer has spread beyond the kidney? So, the staging itself can get a little complicated, but I feel like for in our clinic, for patients and their caregivers, that the key distinction is, is the cancer confined to the kidney where this would come out in a single surgical procedure, or is there evidence of spread beyond the kidney where surgery to remove the kidney would not remove all of the suspected cancer?

So, that kind of defines what I would call very practical, two practical scenarios that are related to the stage but a little bit less complex. Once a kidney mass has been identified, if it’s confined to the kidney and it’s highly suspicious by how it looks on a CT scan.

Sometimes the diagnosis is actually made after the surgery, so we actually go right to surgery to remove the kidney, and then the pathology team looks at the tumor and makes a diagnosis after surgery. So, that’s a little unique. In many cancer settings and other cancer types, a biopsy is the first thing that is done.

And sometimes we do do a biopsy, and there may be very good reasons why that’s recommended, but this is a cancer where sometimes the surgery itself is what leads to the actual final diagnosis of a kidney cancer and a specific subtype of kidney cancer.

The pathology report from either a biopsy or a surgical removal of the kidney contains a tremendous amount of information, and it’s often quite complex, and I don’t expect patients to necessarily completely understand everything that’s contained in it.

For patients where the tumor is removed surgically and they are without evidence of cancer, many of the features that tell us a cancer is either low risk to return or high risk are contained as items in that report, so there’s a very specific reason the report is read that way. It’s to convey information to doctors like me who are considering medicines.

To identify if there are higher-risk or lower-risk features and help the medical team counsel a patient about the pros or cons of more treatment. So, I think it is a lot of information, and it’s totally in scope if you have questions about your pathology report or what it means, what the significance of certain items are. To bring those up in a visit with an oncologist, I think that’s very appropriate.

Katherine Banwell: 

So, the information in the pathology report helps you as a doctor focus in on what that specific person needs as far as medicines?

Dr. Evan Hall: 

Yes, so in the example of a patient with a, let’s just use an example of someone with an intermediate to large kidney tumor, no evidence have spread on any of the preoperative scans, they have surgery, and we meet a few weeks later to review the results in the pathology report. That’s going to contain a vital amount of information.

One, is this definitely kidney cancer? Again, for many patients they are presumed to have kidney cancer, they have surgery, and the surgical specimen confirms that. So, the first high-level question is, are we sure this is cancer? And the answer is usually yes. What type? We haven’t talked about that much, but there are several many types of kidney cancer. What we call clear cell renal cell carcinoma, or clear cell kidney cancer, is the most common.

It’s about 75 percent to 80 percent, but there are a dozen plus other types that make up that remaining small fraction of cancer, and certainly if a patient has one of the rarer subtypes, that’s really important in thinking about what the right thing to do is. So, that’s listed in the pathology report. The size of the tumor is a risk factor. The larger tumors are more likely to eventually have recurrence or return of the cancer, so that’s a useful piece of information to have. The grade of the tumor, which is how aggressive it appears under the microscope, low grade, lower risk, high grade, higher risk, and then the presence of unusual features.

So, sometimes the pathologist will comment about what we call sarcomatoid features, which is where the kidney cancer cells start to look like connective tissue or cartilage under the microscope. That’s an aggressive feature that can mean a higher risk that’s useful for us for everyone to know for considering other treatments. So, those are just some of the examples. There are several more things listed that are helpful, but those are important pieces of information, as someone is recovering from surgery, and they’re considering whether they should just go on about their life with a monitoring plan.

Katherine Banwell: 

Yeah.

Dr. Evan Hall: 

Or consider taking some type of medicine to reduce their risk. Having an understanding of what the basic risks are is really helpful.