eMedicine Specialties > Radiology > Genitourinary

Renal Cell Carcinoma: Follow-up

Author: Deborah A Baumgarten, MD, MPH, Associate Professor of Radiology, Associate Director, Diagnostic Radiology Residency Program, Director, Preliminary Radiology Program, Director, Abdominal Imaging Fellowship, Emory University School of Medicine
Coauthor(s): J Kevin Smith, MD, PhD, Professor of Abdominal Imaging, Vice Chair for Veterans Affairs, Department of Radiology, University of Alabama at Birmingham; Chief of Service, Department of Radiology, Birmingham Veterans Affairs Medical Center; Philip Kenney, MD, Professor of Radiology and Chairman, Department of Radiology, University of Arkansas for Medical Sciences
Contributor Information and Disclosures

Updated: Oct 28, 2009

Intervention

Because RCCs are usually resistant to chemotherapy and radiation therapy, surgical resection offers the best likelihood of cure. Patients with unresectable RCCs have a 5-year survival rate of less than 20%.18,19,20,21,22

It used to be thought that when a solitary mass is noted in a patient with suspected RCC, image-guided biopsy is unnecessary. In one older series, fine-needle aspiration of solitary proven RCCs had a yield of 40% definitely malignant, 36% questionably malignant, and 24% negative tumors.
 
However, there has been increasing recognition that there is a high incidence of benign tumors when core biopsies are performed of small enhancing masses prior to definitive therapy. In a series of 488 patients taken directly to surgery, 1.6% of the masses were nonneoplastic and 18% benign. In another series, of 119 patients who underwent core biopsy, 20.1% had benign masses. In an additional series of 152 patients with core biopsies for focal abnormalities, 61 biopsies were benign and only 6 nondiagnostic. In this series, 60.5% of the biopsies impacted patient management.

In a patient with a prior malignancy, lymphoma, or multiple masses, fine-needle aspiration or preferably core biopsy guided with CT or US may prove very helpful in treatment planning. In one series, 31 of 54 biopsies performed for a new renal mass in a patient with a known malignancy proved to be RCC.

Image-guided radiofrequency or cryogenic ablation has been used to treat patients with RCC, especially patients with a high surgical risk, aversion to surgery, or bilateral lesions. The role for these minimally invasive techniques is ever increasing to include indications such as patient preference. Recent studies have reported short-term success rates of up to 97% with 1 or 2 ablation sessions, with size (<3 cm) and noncentral location being significant determinants for tumor eradication in a single session. Complication rates are low. Radiofrequency ablation can also be considered in patients with local recurrence. In patients considered for ablation, preprocedure biopsy is important because, in one series, 10 out of 27 patients (nearly 40%) referred for ablation had a benign diagnosis.

Special Concerns

  • Pregnancy
    • When RCC is suggested in a pregnant patient, US should be considered first for imaging, especially in the first trimester. CT also can be useful and the radiation exposure to the fetus is justifiable, especially if the clinical picture is confusing; any fetal damage is unlikely at the radiation doses typically used. The dose should be kept to a minimum by increasing the pitch and decreasing the microamperes. MRI is good for detecting, characterizing, and staging renal masses and avoids the exposure to ionizing radiation.
    • The use of the most appropriate and accurate diagnostic method (contrast-enhanced CT or MRI) and the most appropriate treatment of the mother is most likely to result in long-term benefit to the fetus. Nephrectomy can be performed with the least morbidity to the mother and fetus in the second trimester and is probably preferable to leaving a malignancy untreated throughout pregnancy.
  • Contrast agent allergy
    • If contrast enhancement is needed, actions can be taken to decrease the risk of an adverse reaction in patients with an allergy to iodinated contrast material. The patient can be premedicated with steroids and histamine blockers. Use of low-osmolar contrast may also help.
    • In patients who have had previous life-threatening reactions, the use of iodinated contrast material should be avoided.
  • Renal insufficiency
    • In patients with renal insufficiency, avoiding or limiting intravenous iodinated contrast material and ensuring adequate hydration is best if the creatinine levels are above 2 and if the patient is not receiving long-term dialysis. Poor renal function also results in failure to opacify the kidneys and collecting system, limiting evaluation of the kidneys. In patients with renal insufficiency, MRI is an excellent alternative to CT.
    • Another consideration in patients with abnormal renal function not yet requiring dialysis is that nephrectomy will likely result in dialysis dependence. In these patients, accurate diagnosis and staging is imperative and is probably best accomplished by using contrast-enhanced MRI.
    • In patients already undergoing dialysis, iodinated contrast material does not need to be avoided, and in fact CT is preferable to MRI due to the small but documented risk of nephrogenic systemic fibrosis (NSF).
 


More on Renal Cell Carcinoma

Overview: Renal Cell Carcinoma
Imaging: Renal Cell Carcinoma
Follow-up: Renal Cell Carcinoma
Multimedia: Renal Cell Carcinoma
References
Further Reading
[ CLOSE WINDOW ]

References

  1. American Cancer Society. Cancer reference information, detailed guide: kidney cancer staging. American Cancer Society Web site. Available at: http://www.cancer.org/docroot/CRI/content/CRI_2_4_3X_How_is_kidney_cancer_staged_22.asp?sitearea=. Accessed October 6, 2006. [Full Text].

  2. American Cancer Society. Cancer reference information, detailed guide: kidney cancer statistics. American Cancer Society Web site. Available at: http://www.cancer.org/docroot/cri/content/cri_2_4_1x_what_are_the_key_statistics_for_kidney_cancer_22.asp?sitearea=&level=. Accessed October 27, 2009. [Full Text].

  3. Oliva MR, Glickman JN, Zou KH, Teo SY, Mortelé KJ, Rocha MS, et al. Renal cell carcinoma: t1 and t2 signal intensity characteristics of papillary and clear cell types correlated with pathology. AJR Am J Roentgenol. Jun 2009;192(6):1524-30. [Medline].

  4. Guzzo TJ, Pierorazio PM, Schaeffer EM, Fishman EK, Allaf ME. The accuracy of multidetector computerized tomography for evaluating tumor thrombus in patients with renal cell carcinoma. J Urol. Feb 2009;181(2):486-90; discussion 491. [Medline].

  5. Taouli B, Thakur RK, Mannelli L, Babb JS, Kim S, Hecht EM, et al. Renal lesions: characterization with diffusion-weighted imaging versus contrast-enhanced MR imaging. Radiology. May 2009;251(2):398-407. [Medline].

  6. Chae EJ, Kim JK, Kim SH, et al. Renal cell carcinoma: analysis of postoperative recurrence patterns. Radiology. Jan 2005;234(1):189-96. [Medline].

  7. DeRoche T, Walker E, Magi-Galluzzi C, Zhou M. Pathologic characteristics of solitary small renal masses: can they be predicted by preoperative clinical parameters?. Am J Clin Pathol. October 2008;130:560-564. [Medline].

  8. Bulnes Vázquez V, Alvarez-Múgica M, Fernández Gómez JM, Nava Tomás E, Jalón Monzón A, Meilán Martínez A. [Clinicopathologic features of renal cell carcinoma incidentally detected through radiological studies]. Actas Urol Esp. Nov-Dec 2008;32(10):976-84. [Medline].

  9. Gabr AH, Gdor Y, Roberts WW, Wolf JS Jr. Radiographic surveillance of minimally and moderately complex renal cysts. BJU Int. Apr 2009;103(8):1116-9. [Medline].

  10. Wang ZJ, Coakley FV, Fu Y, Joe BN, Prevrhal S, Landeras LA, et al. Renal cyst pseudoenhancement at multidetector CT: what are the effects of number of detectors and peak tube voltage?. Radiology. September 2008;248:910-916. [Medline].

  11. Juluru K, Vogel-Claussen J, Macura KJ, Kamel IR, Steever A, Bluemke DA. MR Imaging in Patients at Risk for Developing Nephrogenic Systemic Fibrosis: Protocols, Practices, and Imaging Techniques to Maximize Patient Safety. Radiographics. Epub ahead of print:[Medline].

  12. Hill KL, Lipson AC, Sheehan JM. Brain magnetic resonance imaging changes after sorafenib and sunitinib chemotherapy in patients with advanced renal cell and breast carcinoma. J Neurosurg. Feb 6 2009;[Medline].

  13. Wu B, Peng WJ, Gu YJ, Yang TX, Jiang ZX, Zhang HL, et al. [MR imaging features of different renal cell carcinoma subtypes.]. Zhonghua Zhong Liu Za Zhi. Nov 2008;30(11):825-30. [Medline].

  14. Sun MR, Ngo L, Genega EM, Atkins MB, Finn ME, Rofsky NM, et al. Renal cell carcinoma: dynamic contrast-enhanced MR imaging for differentiation of tumor subtypes--correlation with pathologic findings. Radiology. Mar 2009;250(3):793-802. [Medline].

  15. Tamai H, Takiguchi Y, Oka M. Contrast-enhanced ultrasonography in the diagnosis of solid renal tumors. J Ultrasound Med. Dec 2005;24(12):1635-40.

  16. Roy C, Gengler L, Sauer B, Lang H. [Role of contrast enhanced US in the evaluation of renal tumors]. J Radiol. Nov 2008;89(11 Pt 1):1735-44. [Medline].

  17. Warshauer DM, McCarthy SM, Street L. Detection of renal masses: sensitivities and specificities of excretory urography/linear tomography, US, and CT. Radiology. Nov 1988;169(2):363-5.

  18. Gervais DA, Arellano RS, McGovern FJ. Radiofrequency ablation of renal cell carcinoma: part 2, Lessons learned with ablation of 100 tumors. AJR Am J Roentgenol. Jul 2005;185(1):72-80.

  19. Gervais DA, McGovern FJ, Arellano RS. Radiofrequency ablation of renal cell carcinoma: part 1, Indications, results, and role in patient management over a 6-year period and ablation of 100 tumors. AJR Am J Roentgenol. Jul 2005;185(1):64-71.

  20. Lebret T, Poulain JE, Molinie V, Herve JM, Denoux Y, Guth A, et al. Percutaneous core biopsy for renal masses: indications, accuracy and results. J Urol. October 2007;178:1184-1188. [Medline].

  21. Maturen KE, Nghiem HV, Caoili EM, Higgins EG, Wolf JS Jr, Wood DP Jr. Renal mass core biopsy: accuracy and impact on clinical management. AJR Am J Roentgenol. February 2007;188:563-570. [Medline].

  22. Silverman SG, Israel GM, Herts BR, Richie JP. Management of the incidental renal mass. Radiology. October 2008;249:16-31. [Medline].

  23. Bae KT, Heiken JP, Siegel CL, Bennett HF. Renal cysts: is attenuation artifactually increased on contrast- enhanced CT images?. Radiology. Sep 2000;216(3):792-6. [Medline].

  24. Birnbaum BA, Jacobs JE, Ramchandani P. Multiphasic renal CT: comparison of renal mass enhancement during the corticomedullary and nephrographic phases. Radiology. Sep 1996;200(3):753-8. [Medline].

  25. Campbell SC, Novick AC, Herts B, et al. Prospective evaluation of fine needle aspiration of small, solid renal masses: accuracy and morbidity. Urology. Jul 1997;50(1):25-9. [Medline].

  26. Choyke PL. Detection and staging of renal cancer. Magn Reson Imaging Clin N Am. Feb 1997;5(1):29-47. [Medline].

  27. Choyke PL, Glenn GM, Walther MM, et al. Hereditary renal cancers. Radiology. Jan 2003;226(1):33-46. [Medline].

  28. Coll DM, Herts BR, Davros WJ, et al. Preoperative use of 3D volume rendering to demonstrate renal tumors and renal anatomy. Radiographics. Mar-Apr 2000;20(2):431-8. [Medline].

  29. Coulam CH, Sheafor DH, Leder RA, et al. Evaluation of pseudoenhancement of renal cysts during contrast-enhanced CT. AJR Am J Roentgenol. Feb 2000;174(2):493-8. [Medline].

  30. Elmore JM, Kadesky KT, Koeneman KS, Sagalowsky AI. Reassessment of the 1997 TNM classification system for renal cell carcinoma. Cancer. Dec 1 2003;98(11):2329-34. [Medline].

  31. Farrell MA, Charboneau WJ, DiMarco DS, et al. Imaging-guided radiofrequency ablation of solid renal tumors. AJR Am J Roentgenol. Jun 2003;180(6):1509-13. [Medline].

  32. Heneghan JP, Spielmann AL, Sheafor DH, et al. Pseudoenhancement of simple renal cysts: a comparison of single and multidetector helical CT. J Comput Assist Tomogr. Jan-Feb 2002;26(1):90-4. [Medline].

  33. Hsu RM, Chan DY, Siegelman SS. Small renal cell carcinomas: correlation of size with tumor stage, nuclear grade, and histologic subtype. AJR Am J Roentgenol. Mar 2004;182(3):551-7. [Medline].

  34. Kier R, Taylor KJ, Feyock AL, Ramos IM. Renal masses: characterization with Doppler US. Radiology. Sep 1990;176(3):703-7. [Medline].

  35. Kim JK, Park SY, Shon JH, Cho KS. Angiomyolipoma with minimal fat: differentiation from renal cell carcinoma at biphasic helical CT. Radiology. Mar 2004;230(3):677-84. [Medline].

  36. Kopka L, Fischer U, Zoeller G, et al. Dual-phase helical CT of the kidney: value of the corticomedullary and nephrographic phase for evaluation of renal lesions and preoperative staging of renal cell carcinoma. AJR Am J Roentgenol. Dec 1997;169(6):1573-8. [Medline].

  37. Kuijpers D, Jaspers R. Renal masses: differential diagnosis with pulsed Doppler US. Radiology. Jan 1989;170(1 Pt 1):59-60. [Medline].

  38. Landis SH, Murray T, Bolden S, Wingo PA. Cancer statistics, 1999. CA Cancer J Clin. Jan-Feb 1999;49(1):8-31, 1. [Medline].

  39. Lockhart ME, Smith JK. Technical considerations in renal CT. Radiol Clin North Am. Sep 2003;41(5):863-75. [Medline].

  40. Macari M, Bosniak MA. Delayed CT to evaluate renal masses incidentally discovered at contrast-enhanced CT: demonstration of vascularity with deenhancement. Radiology. Dec 1999;213(3):674-80. [Medline].

  41. Maki DD, Birnbaum BA, Chakraborty DP, et al. Renal cyst pseudoenhancement: beam-hardening effects on CT numbers. Radiology. Nov 1999;213(2):468-72. [Medline].

  42. Mayo-Smith WW, Dupuy DE, Parikh PM, et al. Imaging-guided percutaneous radiofrequency ablation of solid renal masses: techniques and outcomes of 38 treatment sessions in 32 consecutive patients. AJR Am J Roentgenol. Jun 2003;180(6):1503-8. [Medline].

  43. McLaughlin CA, Chen MY, Torti FM, et al. Radiofrequency ablation of isolated local recurrence of renal cell carcinoma after radical nephrectomy. AJR Am J Roentgenol. Jul 2003;181(1):93-4. [Medline].

  44. Narumi Y, Hricak H, Presti JC Jr, et al. MR imaging evaluation of renal cell carcinoma. Abdom Imaging. Mar-Apr 1997;22(2):216-25. [Medline].

  45. Nissenkorn I, Bernheim J. Multicentricity in renal cell carcinoma. J Urol. Mar 1995;153(3 Pt 1):620-2. [Medline].

  46. Outwater EK, Bhatia M, Siegelman ES, et al. Lipid in renal clear cell carcinoma: detection on opposed-phase gradient-echo MR images. Radiology. 1997;205:103-7. [Medline].

  47. Pretorius ES, Wickstrom ML, Siegelman ES. MR imaging of renal neoplasms. Magn Reson Imaging Clin N Am. Nov 2000;8(4):813-36. [Medline].

  48. Ramos IM, Taylor KJ, Kier R, et al. Tumor vascular signals in renal masses: detection with Doppler US. Radiology. Sep 1988;168(3):633-7. [Medline].

  49. Rybicki FJ, Shu KM, Cibas ES, et al. Percutaneous biopsy of renal masses: sensitivity and negative predictive value stratified by clinical setting and size of masses. AJR Am J Roentgenol. May 2003;180(5):1281-7. [Medline].

  50. Scatarige JC, Sheth S, Corl FM, Fishman EK. Patterns of recurrence in renal cell carcinoma: manifestations on helical CT. AJR Am J Roentgenol. Sep 2001;177(3):653-8. [Medline].

  51. Scialpi M, Di Maggio A, Midiri M, et al. Small renal masses: assessment of lesion characterization and vascularity on dynamic contrast-enhanced MR imaging with fat suppression. AJR Am J Roentgenol. Sep 2000;175(3):751-7. [Medline].

  52. Siegel CL, Fisher AJ, Bennett HF. Interobserver variability in determining enhancement of renal masses on helical CT. AJR Am J Roentgenol. May 1999;172(5):1207-12. [Medline].

  53. Suh M, Coakley FV, Qayyum A, et al. Distinction of renal cell carcinomas from high-attenuation renal cysts at portal venous phase contrast-enhanced CT. Radiology. Aug 2003;228(2):330-4. [Medline].

  54. Szolar DH, Kammerhuber F, Altziebler S, et al. Multiphasic helical CT of the kidney: increased conspicuity for detection and characterization of small (< 3-cm) renal masses. Radiology. Jan 1997;202(1):211-7. [Medline].

  55. Takebayashi S, Hidai H, Chiba T, et al. Using helical CT to evaluate renal cell carcinoma in patients undergoing hemodialysis: value of early enhanced images. AJR Am J Roentgenol. Feb 1999;172(2):429-33. [Medline].

  56. Tuncali K, vanSonnenberg E, Shankar S. Evaluation of patients referred for percutaneous ablation of renal tumors: importance of a preprocedural diagnosis. AJR Am J Roentgenol. Sep 2004;183(3):575-82. [Medline].

  57. Vallancien G, Torres LO, Gurfinkel E. Incidental detection of renal tumours by abdominal ultrasonography. Eur Urol. 1990;18(2):94-6. [Medline].

  58. Yoshimitsu K, Honda H, Kuroiwa T. MR detection of cytoplasmic fat in clear cell renal cell carcinoma utilizing chemical shift gradient-echo imaging. J Magn Res Imag. 1999;9:579-85. [Medline].

  59. Zagoria RJ, Hawkins AD, Clark PE, et al. Percutaneous CT-guided radiofrequency ablation of renal neoplasms: factors influencing success. AJR Am J Roentgenol. Jul 2004;183(1):201-7. [Medline].

  60. Zeman RK, Zeiberg A, Hayes WS, et al. Helical CT of renal masses: the value of delayed scans. AJR Am J Roentgenol. Sep 1996;167(3):771-6. [Medline].

[ CLOSE WINDOW ]

Keywords

renal cell carcinoma, renal adenomas, clear cell carcinomas, RCC, hypernephromas, kidney cell carcinoma, kidney carcinoma, nephric carcinoma, nephric cell carcinoma, renal cancer, kidney cancer, nephric cancer, renal cancer, kidney cell cancer

[ CLOSE WINDOW ]

Contributor Information and Disclosures

Author

Deborah A Baumgarten, MD, MPH, Associate Professor of Radiology, Associate Director, Diagnostic Radiology Residency Program, Director, Preliminary Radiology Program, Director, Abdominal Imaging Fellowship, Emory University School of Medicine
Deborah A Baumgarten, MD, MPH is a member of the following medical societies: Alpha Omega Alpha, American Association for Women Radiologists, American College of Radiology, American Medical Association, American Roentgen Ray Society, Association of Program Directors in Radiology, Association of University Radiologists, Radiological Society of North America, Sigma Xi, and Society of Uroradiology
Disclosure: Nothing to disclose.

Coauthor(s)

J Kevin Smith, MD, PhD, Professor of Abdominal Imaging, Vice Chair for Veterans Affairs, Department of Radiology, University of Alabama at Birmingham; Chief of Service, Department of Radiology, Birmingham Veterans Affairs Medical Center
J Kevin Smith, MD, PhD is a member of the following medical societies: Alpha Omega Alpha, American College of Radiology, American Roentgen Ray Society, International Society for Magnetic Resonance in Medicine, Radiological Society of North America, and Society of Radiologists in Ultrasound
Disclosure: Nothing to disclose.

Philip Kenney, MD, Professor of Radiology and Chairman, Department of Radiology, University of Arkansas for Medical Sciences
Philip Kenney, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Radiology, American Roentgen Ray Society, Association of University Radiologists, Radiological Society of North America, and Society of Uroradiology
Disclosure: Nothing to disclose.

Medical Editor

Steven Perlmutter, MD, FACR, Associate Professor of Clinical Radiology, School of Medicine at Stony Brook University; Medical Director of Radiology, Peconic Bay Medical Center
Steven Perlmutter, MD, FACR is a member of the following medical societies: American College of Radiology, American Institute of Ultrasound in Medicine, American Medical Association, American Roentgen Ray Society, Association of Program Directors in Radiology, Association of University Radiologists, Medical Society of the State of New York, Radiological Society of North America, Society of Breast Imaging, Society of Nuclear Medicine, and Society of Uroradiology
Disclosure: Nothing to disclose.

Pharmacy Editor

Bernard D Coombs, MB, ChB, PhD, Consulting Staff, Department of Specialist Rehabilitation Services, Hutt Valley District Health Board, New Zealand
Disclosure: Nothing to disclose.

Managing Editor

Arnold C Friedman, MD, FACR, Associate Chairman, Department of Radiology, University of Florida Health Science Center; Chief, Department of Radiology, Shands-Jacksonville Hospital
Arnold C Friedman, MD, FACR is a member of the following medical societies: American College of Radiology, American Institute of Ultrasound in Medicine, American Roentgen Ray Society, Association of University Radiologists, and Radiological Society of North America
Disclosure: Nothing to disclose.

CME Editor

Robert M Krasny, MD, Resolution Imaging Medical Corporation
Robert M Krasny, MD is a member of the following medical societies: American Roentgen Ray Society and Radiological Society of North America
Disclosure: Nothing to disclose.

Chief Editor

Eugene C Lin, MD, Consulting Radiologist, Virginia Mason Medical Center; Clinical Assistant Professor of Radiology, University of Washington School of Medicine
Eugene C Lin, MD is a member of the following medical societies: American College of Nuclear Medicine, American College of Radiology, Radiological Society of North America, and Society of Nuclear Medicine
Disclosure: Nothing to disclose.

 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.