Renal-cell CA: An opportunity for cardiologists to make Hannibal proud

Oct 3, 2011 09:25 EDT

I cleaned out a bathroom drawer a couple of weeks ago. Far in the back, on very feminine stationary, was a fancy letter "S" wearing a big showy hat accentuated with purple and blue flowers. On it was written a beautiful thank-you note:

MWS:
Words can't begin to tell you how much your calls and visits have meant to me. The morning of surgery, everyone was so kind and helpful, but it was your bear-hug that kept my mind straight. The fall arrangement is beautiful and is on my kitchen bar as an ever reminder of all the support and love of friends and family. Your calls after I have come home mean so much too. . . . Keep me in your prayers.
Love and God Bless,
Sherry
9/26/2006

Sherry was a stout woman and a force to be reckoned with in the hospital marketing world. She was a devoted wife, mother, and new mother-in- law. As the only child of aging parents who doted on her, she had always been the center of well-deserved attention. While teaching a night class at the local university, she developed severe flank pain. She finished her lecture and went home. The next day she was pale and diaphoretic. Her hemoglobin was only 6.0. A few days later, the nearly 7 cm tumor was resected. After several rounds of chemo, there was no good news, so she switched oncologists. There was more chemo, highly experimental and fraught with danger. Five years ago this autumn, Sherry began her battle and four years ago, she was defeated. Despite pulling out all the stops, she died of renal-cell carcinoma, refusing a no-code status even at the very end. A cowardly rogue tumor won the year-long battle by lurking in the shadows, hiding, waiting . . . because it knows it can be beaten if it can be detected early. It may have destroyed her body but not her will to live and not her desire to help others. The thank-you note reminded me that I have a job to do. I know she would want me to tell her story so that others might have a chance.

Renal-cell carcinoma represents around 3% of all adult malignancies, but it accounts for around 75% of the carcinomas I find, closely followed by gut and lung cancer. One year, I diagnosed three. I might skip a year and then diagnose two. This year, I've already hunted and killed two GU tumors. It lives where I live; in a world of cigarette smoking, hypertension, and obesity. It is easily detectible by a simple ultrasound but is often obscured by an economy obsessed by cost/benefit ratio. In this current environment of healthcare reform and conservative workups, I fear the death rates will only increase. There are 58 000 kidney cancers annually in the US and 13 000 deaths, 80% of them renal-cell carcinomas. I submit it's time we leave this horrifying discovery to chance no longer. We should stalk it with the same voracity as the fictional character Hannibal Lecter stalked his delicacies and then enjoyed them "with some fava beans and a nice Chianti." Guidelines writers need to help us turn the hunter into the hunted.

Hematuria and flank pain are easy red flags for a renal-cell tumor, but it's not what leads me to the diagnosis most often. I discover this sinister tumor quite by accident and often in a patient who is largely ignored by the current guidelines for screening, which include: 

• Patients with end-stage renal failure on dialysis.
• Patients with Von Hippel Lindau (VHL) syndrome or tuberous sclerosis.
• Relatives of patients with VHL or with familial incidence of RCC.

 

A few years ago, a patient in her late 40s was referred for chest pain; at times more right-sided than left. Due to the atypical nature of her presenting symptoms, I asked for a RUQ ultrasound, and bingo, there the cowardly creature sat, staring back at us, perched upon her kidney, a serial killer of whom "Dexter" could be envious. It waits for an opportune moment to steal 30 to 40 years of quality life from the innocent and the unsuspecting. Due to the expertise of one wielding a Bard-Parker blade, that patient is now many years free of disease and likely a grandmother, no less. She stopped in a few years later just to tell me she had not forgotten my saving her life. I told her I really could take no credit for the accidental discovery. It was a blessing but I thanked her anyway.

I've followed a gentleman in his mid-60s for 15 years with known hypertension and an old CABG. He recently visited me because his previously well-controlled blood pressure was now problematic. Using the excuse of "recent exacerbation of previously well-controlled hypertension," a renal-artery Doppler was ordered, which forced a renal ultrasound that resulted in the discovery of yet another tumor. His wife phoned Friday to tell us his surgery, a partial nephrectomy, went well at Vanderbilt University. He is now resting comfortably at home with a good long-term prognosis. I celebrated my latest tumor "kill" with a big broad smile and a bike ride. 

Doctors, if you can't get your middle-aged hypertension patient's insurance company to pay for it, invite your patient to seek out a roving ultrasound unit where they can shell out $99 out-of-pocket dollars for a chance at life. Sherry would tell you it's worth it. Do it in honor of Sherry and for all the "undiagnosed Sherry's" out there who deserve a chance. Guidelines for screening are inadequate, so it's up to us as cardiologists to develop our own. Together we can turn the hunter into the hunted. Make Hannibal proud.