What are the next steps if the Renal Cancer Panel (RCP) test is not available?

Alternative Diagnostic Approaches When Renal Cancer Panel Test Is Unavailable

When the Renal Cancer Panel test is not available, clinicians should proceed with comprehensive cross-sectional imaging and laboratory evaluation to characterize and stage the renal mass. 1, 2

Initial Diagnostic Evaluation

• Obtain high-quality, multiphase, cross-sectional abdominal imaging (CT or MRI) to characterize the renal mass, assess tumor complexity, evaluate contrast enhancement, and determine presence/absence of fat 1
• Chest imaging (preferably CT) is mandatory to evaluate for possible thoracic metastases 1, 2
• Laboratory evaluation should include comprehensive metabolic panel, complete blood count, and urinalysis 1, 2
• Additional laboratory tests to consider: lactate dehydrogenase, serum-corrected calcium, C-reactive protein, and erythrocyte sedimentation rate 1
• Assign CKD stage based on glomerular filtration rate and degree of proteinuria 1, 2

Advanced Characterization

• For solid or Bosniak 3/4 complex cystic renal masses, renal mass biopsy provides histopathological confirmation with high sensitivity and specificity 1, 2
• Renal mass biopsy is especially indicated before treatment with ablative therapies and in patients with metastatic disease before starting systemic treatment 1, 2
• MRI may provide additional information when investigating local advancement and venous involvement by tumor thrombus, or when intravenous contrast cannot be used 1
• Bone scan is not recommended for routine clinical practice unless indicated by clinical symptoms (bone pain), elevated alkaline phosphatase, or radiographic findings suggestive of bony metastases 1
• Brain CT/MRI is only indicated for patients with acute neurological signs or symptoms 1

Risk Assessment

• For localized disease, risk assessment models such as the Stage Size Grade and Necrosis (SSIGN) score or the UCLA Integrated Staging System (UISS) can be used to assess the risk of progression 1
• Factors such as pathological T category, regional lymph node status, tumor size, nuclear grade, and histological tumor necrosis contribute to risk stratification 1
• Male sex and tumor size are the most reliable predictors of malignancy 1

Special Considerations

• Genetic counseling should be considered for patients ≤46 years of age, those with multifocal or bilateral renal masses, or if personal/family history suggests familial renal neoplastic syndrome 2
• Approximately 2-3% of RCC are hereditary with several autosomal dominant syndromes described, each with distinct genetic basis and phenotype 1
• For patients with metastatic disease, referral to medical oncology is recommended for consideration of systemic therapy options 1, 3

Management Pathway

• For patients with solid or Bosniak 3/4 complex cystic renal masses where the anticipated oncologic benefits of intervention outweigh the risks, intervention should be recommended 1
• Active surveillance with potential for delayed intervention may be considered in select patients, with close clinical and cross-sectional imaging surveillance 1
• Treatment options include partial or radical nephrectomy, ablative techniques, or active surveillance depending on tumor characteristics and patient factors 3, 4

Remember that renal cell carcinoma accounts for 90% of renal cancers, with clear cell subtype being the most common (75-80% of cases), and more than 50% of renal masses are diagnosed incidentally 2, 3.