Evaluation of Renal Cell Carcinoma: History, Laboratory, and Imaging
For suspected RCC, obtain a comprehensive metabolic panel, complete blood count, and urinalysis, followed by contrast-enhanced CT of the chest, abdomen, and pelvis for definitive staging. 1
History Taking
Presenting Symptoms
- Incidental detection occurs in >50% of cases during abdominal imaging for unrelated conditions 2, 1
- Classic triad (flank pain, gross hematuria, palpable abdominal mass) is now uncommon but suggests locally advanced or metastatic disease 2, 1
- Metastatic symptoms include bone pain or pulmonary nodules 2
- Paraneoplastic syndromes manifest as hypercalcemia, unexplained fever, erythrocytosis, or wasting syndromes 2, 1
Risk Factor Assessment
- Smoking history (active and passive exposure) 2
- Hypertension (though anti-hypertensive medications are not independently associated with RCC) 2
- Obesity 2
- End-stage renal failure and acquired renal cystic disease 2
- Tuberous sclerosis 2
Hereditary Syndrome Screening
- Age ≤46 years warrants genetic counseling consideration 1
- Multifocal or bilateral renal masses suggest hereditary syndromes 1
- Family history of Von Hippel-Lindau disease or other autosomal dominant syndromes (approximately 2-3% of RCC cases are hereditary) 2, 1
Blood Investigations
Mandatory Laboratory Tests
The following tests serve both diagnostic and prognostic purposes: 2, 1
- Serum creatinine to assess renal function 2, 1
- Hemoglobin (anemia is a poor prognostic factor) 2, 1
- Leukocyte and platelet counts 2, 1
- Lactate dehydrogenase (LDH) (elevated levels indicate poor prognosis) 2, 1
- Serum-corrected calcium (hypercalcemia is a common paraneoplastic syndrome) 2, 1
- Complete blood count 1
- Comprehensive metabolic panel 1
- Urinalysis 1
Additional Inflammatory Markers
- C-reactive protein (CRP) has prognostic value 2, 1
- Erythrocyte sedimentation rate may be considered 2
- Lymphocyte-to-neutrophil ratio 1
Chronic Kidney Disease Classification
- eGFR and proteinuria should be assessed to classify CKD stage 1
Imaging Studies
Initial Detection
Ultrasonography is the most common initial imaging modality that suggests RCC diagnosis 2, 3
Definitive Staging (Mandatory)
Contrast-enhanced CT of chest, abdomen, and pelvis is mandatory for accurate staging 2, 1. This allows assessment of:
Chest CT is the most sensitive approach for thoracic staging 2
MRI Indications
MRI provides additional information in specific scenarios: 2, 1
- Local advancement assessment 2
- Venous tumor thrombus involvement 2, 1
- Contraindication to intravenous contrast 2
- Problem-solving for undefined renal lesions 3
Imaging NOT Recommended Routinely
The following are NOT recommended for routine staging unless clinically indicated: 2, 1
- Bone scan (only if elevated alkaline phosphatase, bone pain, or abnormal radiologic findings) 2
- Brain CT or MRI (only with neurologic symptoms) 2
- Pelvic imaging (only if clinically indicated) 2
- PET scan is not standard for RCC diagnosis and staging 2, 3
Tissue Diagnosis
Renal Mass Biopsy Indications
Core biopsy provides histopathological confirmation with high sensitivity and specificity 2, 1. It is specifically indicated:
- Before ablative therapies 2, 1
- In metastatic disease before systemic treatment 2, 1
- When diagnosis is uncertain 1
Final histopathological diagnosis is based on nephrectomy specimen when available 2
Common Pitfalls to Avoid
- Do not routinely order bone scans or brain imaging in asymptomatic patients, as this increases cost without improving outcomes 2
- Do not skip chest CT in favor of chest radiograph for initial staging, as CT is more sensitive 2
- Do not forget genetic counseling for young patients (≤46 years) or those with bilateral/multifocal disease 1
- Do not rely on PET scans for routine RCC staging, as they are not standard 2