If renal cancer is suspected, the patient should be referred to a Urology Department for further investigation and possible treatment.

• Medical record entry focusing on symptoms, family history, risk factors, comorbidity and a full physical examination
• Urine test strip for measurement of protein, blood, leukocytes and nitrite
• Blood tests + ECG
  • Haematology (Hb, leukocytes with differential count + thrombocytes)
  • Fluid counts (creatinine, urea, sodium and potassium) incl. ionised calcium
  • Liver counts (ALAT, ASAT, alkaline phosphatase, bilirubin and LDH) and coagulation counts (INR and APTT)
  • CRP

• Cystoscopy (bladder tumours/polyps)
• CT urography (CT scan of the urinary tract without and with contrast (preferably in 3 phases, but otherwise in 2 phases – venous phase and excretion phase)) which can be used to visualise:
  • stones (without contrast)
  • tumours/changes in kidneys (venous phase). The presence of contrast charge in a tumour is measured by comparing the hounsfield unit (HU) before and after contrast. If there is a difference of 15 HU, there is a contrast charge and a tumour is suspected
  • tumours/changes in the excretory urinary tract (excretion phase))

• CT urography can also be used to assess:
  • tumour anatomy: position, size, involvement of pelvis
  • possible involvement of the renal vein: tumour thrombus and its range
  • spread to regional lymph nodes
  • spread to other abdominal organs

• CT of the thorax. If kidney cancer is suspected, a CT scan of the thorax should be performed to determine whether there is further spread. CT scan of thorax and abdomen also included in staging of kidney cancer
• Renography to assess the drainage conditions and functional distribution between the 2 kidneys
• An ultrasound scan of the kidney with contrast can be used to differentiate between cysts and solid tumours if it cannot be clarified by CT alone – either because the size or the patient cannot tolerate IV contrast in connection with the CT scan. Ultrasound scanning is also used as a guide when taking a biopsy from a kidney tumour
• Histological diagnosis. The diagnosis of kidney cancer can only be made following a histological diagnosis, which is either obtained by an ultrasound-guided biopsy of the kidney or the tumour is surgically removed
  • If the tumour is <4 cm, biopsy is always recommended before deciding on treatment, as previous studies have shown that around 20% of removed tumours <4 cm were benign
  • In the case of disseminated disease, biopsy from both the renal tumour and a metastasis is recommended

1. ESMO, DaRenCa and NCCN guidelines