Radiography
Findings
Plain radiography
Plain radiographic findings often are unrevealing in patients with RCC, unless the mass contains detectable calcification or is large enough to distort the normal renal contour. Plain radiography has no role in the primary search for RCC or in the follow-up observation of patients with RCC because of its limited sensitivity and specificity.
Intravenous urography
Intravenous urography (IVU) is also limited in depicting RCCs. Large lesions, which can distort the renal contour or the collecting system, may be detected with IVU. If RCC is suggested, further imaging with CT or MRI is necessary to confirm a solid mass and to stage the disease. If the lesion appears to be a cyst, US is the next best test in the patient's workup.
Findings of RCC are nonspecific and include mass effect on the collecting system, distortion of the renal contour, enlargement of a portion of the kidney, and calcifications. If good nephrotomograms are obtained at peak renal enhancement, most RCCs are less attenuating than surrounding renal parenchyma. Renal vein invasion may be inferred if contrast material excretion by the affected kidney is poor or absent. Alternatively, this finding may result from extensive involvement of the kidney or ureteral obstruction caused by mass effect.
Degree of Confidence
In any patient with normal IVU findings and persistent hematuria or other results suggestive of RCC, CT or MRI should be performed.
False Positives/Negatives
As noted above in Limitations of Techniques, plain radiography and IVU have substantial limitations in the detection of RCCs. These techniques should not be used as the primary modalities in the workup of suspected RCC.
Computed Tomography
Case 5. Typical renal cell carcinoma. CT scan obtained before contrast enhancement has an attenuation measurement of 33.9 HU.
Case 5. Typical renal cell carcinoma. Contrast-enhanced CT scan has an attenuation measurement of 75.8 HU.
Case 6. Multifocal renal cell carcinoma in a patient with Von Hippel-Lindau disease. Contrast-enhanced CT scan.
Case 6. Multifocal renal cell carcinoma in a patient with Von Hippel Lindau disease. Patient had already undergone a right nephrectomy. Contrast-enhanced CT scan.
Case 7. Multifocal renal cell carcinoma in patient presenting with palpable mass. Nonenhanced CT scan.
Case 7. Multifocal renal cell carcinoma. Nonenhanced CT scan.
Case 7. Multifocal renal cell carcinoma. Contrast-enhanced CT scan.
Case 7. Multifocal renal cell carcinoma. Contrast-enhanced CT scan.
Case 8. Cystic renal cell carcinoma. Nonenhanced CT scan with an attenuation measurement of 25.8 HU.
Case 8. Cystic renal cell carcinoma. Contrast-enhanced CT scan with an attenuation measurement of 47.1 HU.
Findings
A dedicated renal CT examination consists of thin-section (2.5-5 mm) helical imaging of the kidneys before the intravenous administration of contrast agent, followed by imaging 60-70 seconds and 3-5 minutes after administration of the contrast agent. The imaging parameters (kilovoltage, microamperage, field of view, section thickness) should be kept constant for all phases of imaging to enable comparison of the attenuation measurements. The addition of an arterial phase CT (either with bolus tracking or after a 20-25 second delay) with thin slices (1-2 mm) may be helpful to evaluate arterial anatomy, especially if partial resection is contemplated or if renal parenchymal or vascular anomalies are suspected.4,10
Historically, enhancement was considered present if the attenuation of the lesion increased by more than 10 HU from baseline. However, with recent advances in CT hardware, this definition may need to be changed to 15-20 HU.
On initial nonenhanced CT scans, RCCs may appear as isoattenuating, hypoattenuating, or hyperattenuating relative to the remainder of the kidney. Calcifications may be present and are usually amorphous and internal, although rimlike calcifications can also be present.
On contrast-enhanced CT scans, RCC is usually solid, and decreased attenuation suggestive of necrosis is often present. Sometimes RCC is a predominantly cystic mass, with thick septa and wall nodularity.
RCC may also appear as a completely solid and highly enhancing mass.
Staging of RCC, which can be performed by using CT or MRI, includes the assessment of ipsilateral or contralateral adrenal involvement, direct extension into adjacent organs, enlargement of retroperitoneal lymph nodes, invasion of the ipsilateral renal vein (with or without extension into the inferior vena cava), and distant metastatic disease (liver, bone, lungs). Retrocrural, subcarinal, or mediastinal lymph nodes can also be enlarged.
Degree of Confidence
If a solitary mass is enhancing, the degree of confidence in diagnosing RCC is high. When masses are multiple, metastatic disease and lymphoma must be considered, especially if the patient has a history of a primary malignancy. When a mass is predominantly cystic, the confidence level decreases. In these patients, US may be useful.
False Positives/Negatives
False-positive results
A false-positive diagnosis of enhancement may occur in small masses. This so-called pseudoenhancement may be the result of reconstruction algorithms, beam-hardening artifact, or cupping artifact. It is more pronounced on multi-detector spiral CT scans than on single-detector spiral CT scans. In patients with these findings, MRI or US is helpful in proving that the lesions are cysts. In patients in whom nonenhanced imaging was not obtained, differentiation of solid masses from hyperattenuating cysts (Bosniak class 2 lesions) may be difficult. In one series, RCCs were significantly larger, had greater mean attenuation (>70 HU), and had increased central heterogeneity compared with hyperattenuating cysts.
Occasionally, masses are predominantly cystic but indeterminate because of septa or nodularity (Bosniak class 3 lesions). The lesions are often complex cysts, but they may be removed because of their suggestive appearance.
Briefly, the Bosniak classification of renal masses is as follows: class I includes simple cysts; class II, minimally complicated but overwhelmingly benign masses with thin septa, hyperattenuation, or small amounts of mural or septal calcification; class III, moderately complicated masses with mural nodularity, thick septa, or irregular or thick calcifications that often require surgical exploration; and class IV, significantly complicated and generally malignant masses with thick and irregular enhancing regions and definite solid components.
Oncocytomas cannot be reliably differentiated from RCCs without pathologic analysis. Macroscopic areas of fat in the tumor mass are reported in RCC, but they are extremely rare. Almost all renal tumors with measurable areas of fat are angiomyolipomas (AMLs); however, some AMLs do not contain visible fat and may be mistaken for RCCs. In one series, homogeneous and prolonged enhancement were valuable predictors for differentiation of AML with minimal fat from RCC. High attenuation on nonenhanced CT scans and the degree of enhancement were helpful but less valuable.
False-negative results
A false-negative diagnosis can occur if the attenuation is not carefully measured before and after the administration of contrast material, if cystic masses are not carefully examined for septa or nodularity, if the enhancement of a lesion is missed (as a result of lack of enhancement at the time of scanning), or if the masses are too small for adequate characterization at the time of their discovery.
In patients with renal failure and long-standing dialysis dependence, detection of an RCC (especially the papillary type) is increased when imaging is performed soon after the contrast bolus passes (in the arterial phase). In patients with normal renal function, imaging during the arterial or cortical phases may make the lesions less visible because the typical hypoenhancement of the tumors cannot be distinguished from the nonenhancement of the adjacent medulla.
Magnetic Resonance Imaging
Case 16. Left renal cell carcinoma in patient who underwent prior right nephrectomy for renal cell carcinoma. T1-weighted axial magnetic resonance image (MRI).
Case 16. Left renal cell carcinoma in patient with prior right nephrectomy for renal cell carcinoma. T2-weighted axial MRI with renal vein invasion and extension of tumor into the inferior vena cava.
Case 16. Left renal cell carcinoma in patient with prior right nephrectomy for renal cell carcinoma. T2-weighted axial MRI obtained above the level in image 38. Tumor extends into the intrahepatic inferior vena cava.
Case 17. Large right renal cell carcinoma with renal vein and inferior vena cava invasion. T2-weighted axial MRI.
Case 17. Large right renal cell carcinoma with renal vein and inferior vena cava invasion. T2-weighted axial MRI.
Case 17. Large right renal cell carcinoma with renal vein and inferior vena cava invasion. T2-weighted coronal MRI.
Case 18. Large right renal cell carcinoma with renal vein and inferior vena cava invasion. T1-weighted axial MRI before contrast enhancement.
Case 18. Large right renal cell carcinoma with renal vein and inferior vena cava invasion. T1-weighted contrast-enhanced axial MRI.
Case 18. Large right renal cell carcinoma with renal vein and inferior vena cava invasion. T2-weighted axial MRI.
Case 19. Left renal cell carcinoma in a patient with polycystic kidney disease. Axial T2-weighted MRI.
Case 19. Left renal cell carcinoma in a patient with polycystic kidney disease. Axial T1-weighted MRI before contrast enhancement.
Case 19. Left renal cell carcinoma in a patient with polycystic kidney disease. Axial T1-weighted contrast-enhanced MRI.
Findings
MRI findings are similar to those of CT, with masses ranging from predominantly cystic with septa or nodularity to solid with enhancement. The numeric criteria for enhancement are not defined for MRI as they are for CT, but MRI signal intensity changes can be measured.11,12,13,14
On nonenhanced T1-weighted images, RCCs usually appear isointense or hypointense relative to the remainder of the kidney. With chemical shift imaging, some clear cell carcinomas show focal or diffuse loss of signal intensity. On T2-weighted images, RCCs are usually hyperintense. Most often, they are heterogeneous.
The presence of necrosis or hemorrhage may alter these signal intensity characteristics. MRI may be especially helpful in imaging the superior or inferior poles of the kidneys, in direct coronal or sagittal imaging, and in determining invasion of venous structures.
Degree of Confidence
The degree of confidence in the diagnosis with MRI is similar to that of CT. That is, confidence is high for lesions showing enhancement and less for cystic lesions. Thus, MRI has no advantage compared with contrast-enhanced CT for the diagnosis of RCC, but MRI is superior to nonenhanced CT.
False Positives/Negatives
As with CT, false-positive findings of RCC can occur with other solid-enhancing masses (metastatic disease, lymphoma, oncocytoma, non–fat-containing AML), which are virtually indistinguishable from RCC when they are solitary and when the relevant history is absent.
As with CT, a false-negative diagnosis can occur if cystic masses are not carefully examined for septa or nodularity, if enhancement of a lesion is missed (as a result of lack of contrast enhancement at the time of scanning), or if the masses are too small for adequate characterization at the time of their discovery.
Ultrasonography
Case 21. Right renal cell carcinoma. Ultrasonogram.
Case 21. Right renal cell carcinoma. Doppler ultrasonogram.
Case 21. Right renal cell carcinoma. Doppler ultrasonogram obtained prior to the intravenous administration of ultrasonographic contrast agent.
Case 21. Right renal cell carcinoma. Doppler ultrasonogram obtained after the intravenous administration of ultrasonographic contrast agent.
Case 22. Left renal cell carcinoma. Ultrasonogram.
Case 22. Left renal cell carcinoma. Nonenhanced CT scan.
Case 22. Left renal cell carcinoma. Contrast-enhanced CT scan.
Case 22. Left renal cell carcinoma. Anterior component of circumaortic renal vein is normal.
Case 22. Left renal cell carcinoma. Posterior component of circumaortic renal vein is normal.
Findings
On sonograms, RCC can be isoechoic, hypoechoic, or hyperechoic relative to the remainder of the renal parenchyma. Smaller lesions with less necrosis are more likely to be hyperechoic and may be confused with AMLs. Isoechoic tumors are detected only by distortion of the renal contour, focal enlargement of a portion of the kidney, or distortion of the central sinus fat.15,16
For the workup in RCC, US is used primarily to differentiate solid masses from simple cysts and to visualize the internal architecture of lesions more effectively than can be accomplished by using CT or MRI.
Recent literature also suggests a role for contrast-enhanced Doppler US (CEUS) in the workup of masses showing poor enhancement at arterial phase CT. In one series of 26 pathologically proven malignant masses, CT failed to show arterial enhancement in 5. In all 5, blood flow was confirmed with CEUS.
Degree of Confidence
Confidence in tumor detection is increased as lesions increase in size. Larger lesions usually are more heterogeneous and more often hypoechoic. In a reported series, a detection rate of 85% was seen in lesions larger than 3 cm.17 A detection rate of less than 60% was seen in lesions smaller than 2 cm.
Confidence also increases if lesions are solid, lobulated, or well differentiated from the normal parenchyma; if they have poor through-transmission; and if they show flow with CEUS.
False Positives/Negatives
False-positive results are rare because US is seldom the sole imaging modality used prior to intervention.
A prominent column of Bertin or fetal lobulation may mimic a solid renal mass and can be resolved with a dedicated CT or MRI examination.
False-negative findings can occur if care is not taken to fully examine all aspects of the kidney, because US is highly operator-dependent. False-negative results are also possible if the RCC is small, isoechoic to the parenchyma, and/or is not contour deforming.
Nuclear Imaging
Findings
In a patient with a suspected renal mass, nuclear medicine studies help in differentiating the mass from a pseudomass (eg, column of Bertin, dromedary hump, fetal lobulation). Scintigraphy with technetium dimethylsuccinic acid demonstrates normal uptake in the region of a pseudomass, whereas a real mass causes a focal photopenic defect.
Bone scanning with technetium methylene diphosphonate is indicated to confirm bony metastatic disease in a patient with RCC and symptoms referable to the skeleton.
Degree of Confidence
In the differentiation of a true mass from a pseudomass, the degree of confidence is high. The specificity of the technique is low in that all types of masses cause photopenic defects if they are large enough.
False Positives/Negatives
Nuclear medicine scintigraphy is not used as the primary modality in the evaluation of suspected RCC. However, it can aid in confirming the presence of a pseudomass.
Angiography
Findings
Noninvasive cross-sectional imaging (CT, MRI, US) has replaced angiography in the workup of patients with known or suspected RCC. Advances in CT angiography and magnetic resonance angiography have diminished the need for preoperative conventional angiographic mapping of the renal vasculature prior to nephron-sparing or minimally invasive surgery. Angiography is still occasionally used if the origin of a tumor (eg, renal vs adrenal) is not certain. In these patients, selective injection of the renal and adrenal arteries, as well as additional vessels, may be necessary.
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Further Reading
Related eMedicine topics
Renal Cell Carcinoma (from Oncology)
Clear Cell Renal Cell Carcinoma
Clear Cell Sarcoma of the Kidney
Kidney, Lymphoma
Cystic Diseases of the Kidney
Clinical guidelines
ACR Appropriateness Criteria Renal Cell Carcinoma Staging
ACR Appropriateness Criteria Follow-up of Renal Cell Carcinoma
Clinical studies
A Phase I Study of Bevacizumab and Sunitinib in Metastatic Renal Cell Carcinoma Patients
A Study Evaluating Tarceva in Combination With Avastin Versus Avastin Alone in Treating
Metastatic Renal Cell Carcinoma
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
