Whenever I have made a no-go decision and find myself with an unscheduled overnight stop, wonderful things happen: an interesting conversation, a great restaurant, or a chill night watching a movie. Sometimes the most important thing isn’t what you’re looking for, it’s what you find along the way. Good piloting requires a constant scan, not fixating straight ahead. Airspeed, altitude, gauges, weather, traffic.
In medicine we also scan; frequent health checks, computerized tomography (CAT scan), magnetic resonance (MRI), positron emission (PET scan), and so on. Thought—if a CAT scan shows a problem is it considered pussytive? And if there is a PET scan, why isn’t there a DOG scan?
These scans are expensive and some involve radiation, so we only deploy them when circumstances demand. And sometimes we don’t see what we were looking for, but we do find something important; modern scans are wonderfully indiscreet, often revealing secrets patients never intended to share. As scanning technology improves, and some seek whole-body scans, these unexpected findings, incidentalomas, are becoming more common.
A few years ago, I wrote about kidneys, extolling the virtues of steak and kidney pie (“My Favorite Pie,” AOPA Pilot magazine, March 2012, page 38). I suspect I persuaded precisely nobody to rush out and order one, but I did hope readers would gain a little more respect for these remarkable organs. This month we’re staying with kidneys, but for a far more sinister reason. Not kidney failure this time—but kidney cancer.
My recent article addressing lung cancer detection with CT scanning long before it is symptomatic came home to roost for me. My childhood friend recently took advantage of a lung cancer CAT scan screening program due to his 10+-year smoking habit. The good news was no lung cancer was seen. However, the radiologist’s eye wandered (in an acceptable manner) and an abnormality in the top of the right kidney was captured and further investigation revealed this to be a cancer. My pal was devastated. He had suffered no symptoms and asked the very common “why me” question. He was rapidly referred to a urologist specializing in cancer, and the diseased organ was removed by the minimally invasive laparoscopic route. One night in the hospital, a few days recovering, and he was back to all his normal activities. Maybe this anecdote should inspire us to call for multiple screening scans for everybody? Because sometimes the most important finding is the one nobody ordered the scan to look for.
Conversely, another of my mates was being investigated for left-sided abdominal pain and the resultant CAT scan showed his belly was normal, but there was an unexpected passenger, a one-inch-diameter nodule in his lung that looked benign, but one must be sure. Therefore, this fellow was investigated using a PET scan and thankfully the nodule was benign, ending several days of anxiety. This nicely illustrates why we should not do blanket scans of every single body part of every symptomless person; we will pick up huge numbers of incidentalomas and likely push healthcare systems into meltdown.
There are several types of cancer originating in the kidney. About 80% are renal cell carcinoma (RCC), otherwise known as renal cell adenocarcinoma, which arises in the nephrons, the little filtering units of the kidney. Others include clear cell, papillary, chromophobe, transitional cell carcinoma, secondary tumors that have spread to the kidney, and Wilm’s tumor or nephroblastoma, a pediatric malignancy.
Risk factors include having a family history, being male and over 60, smoking—which doubles the risk—obesity; hypertension; a rare genetic disorder, Von Hippel-Lindau disease; and certain solvents like trichloroethylene.
If kidney cancer was an aircraft, it would be a stealth fighter, and unlike arthritic knees or backs, symptoms might be camouflaged until quite late in the process. In fact, most patients have no indication that something is wrong. However, there are “three greens” that might suggest this diagnosis, usually when the tumor is quite large: blood in the urine, pain in the flank, and a good clinician can feel a lump. Other symptoms might include weight loss, fatigue, night sweats, and a general sense of being ill.
A doctor will take a full history, examine the whole body carefully, and do a urine dipstick looking for blood. Other investigations include taking blood to evaluate kidney function, diagnose anemia, identify markers of malignancy, and uncover suggestions the cancer has metastasized (spread). Then a CAT scan is done to examine the afflicted organ and evaluate the other kidney and also to look for signs of spread to the local area as well as liver, lungs, and elsewhere. Sometimes a PET scan may supplement the work-up together with general health checks to ascertain fitness for surgery.
Depending on where the cancer is located, surgeons may be able to perform a partial nephrectomy, removing just part of the kidney, thereby preserving function. This is good for small tumors that are not poking through the surface or where the other kidney may not be functioning well. Otherwise, one removes the entire organ together with associated lymph nodes and this can be done, as with my friend, under the guidance of a laparoscope, perhaps with robotic assistance. This requires only tiny incisions, less blood loss and therefore less pain, which leads to faster discharge and recovery and better cosmetic outcome.
Conventional chemotherapy that many associate with cancer treatment has very little effect on the commonest form of kidney cancer, RCC. Likewise, radiotherapy rarely cures advanced disease because RCC is relatively resistant to radiation. However, radiation can be extremely effective at shrinking troublesome secondary deposits, such as those causing bone pain or pressure on the brain or spinal cord, greatly improving quality of life.
Today’s treatments are far more sophisticated. Modern immunotherapy drugs like checkpoint inhibitors help the body’s own immune system recognize and attack cancer cells, while targeted therapies block the blood vessels and growth signals that kidney cancers depend upon. These treatments have transformed the outlook for many patients with metastatic disease. Although they are not usually curative, some people now survive for many years with an excellent quality of life, something that would have been almost unimaginable just two decades ago.
If found early, the outlook is excellent, with more than 90% surviving five years or more. However, with later diagnosis the prognosis is not as rosy. For this reason, follow-up includes repeat CT scans and blood tests to look for early signs of recurrence. In my prior article about yummy British comestibles, I used the plural “kidneys,” but if a determined surgeon has whipped one out, how can one survive with a singular kidney? Surprisingly well, and most people live completely normal lives. The doctor will advise judiciously maintaining hydration, stopping smoking, controlling blood pressure, watching salt and protein intake, and keeping weight healthy. Medications like ibuprofen (NSAIDs) should be used in moderation and one can exercise normally, but contact sports may be a concern as damage to the remaining kidney could be a big problem.
As always, if a new symptom pops up, self-ground and bear in mind that renal cancer is disqualifying until treated. Following kidney removal, the FAA will want the pathology and operative reports, follow-up from treating doctors, update on the remaining kidney’s function, and evidence that the tumor has not returned. Certification after curative surgery is feasible, and one functioning kidney is generally compatible with certification, provided renal function remains adequate and there is no recurrence.
Pilots are trained never to fixate on one instrument. Safe flying depends on maintaining a broad scan because today’s problem may not be where you expect to find it. Sometimes it is wise for pilots to deviate off course to remain on target to fight and fly another day. Modern medicine works in much the same way. Occasionally, the scan ordered for one reason quietly points toward another, and an incidental finding becomes an intentional lifesaver. So, if your physician recommends appropriate screening, don’t dismiss it because you feel perfectly well. Some of the most dangerous diseases make the least noise, and some of the greatest victories in medicine begin with someone noticing something they weren’t looking for. Keep scanning, both in the cockpit and in life, and, as always, fly well!
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