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Patterns of Recurrence in Renal Cell Carcinoma

Manifestations on Helical CT

¹ All authors: Russell H. Morgan Department of Radiology and Radiological Science, The Johns Hopkins Hospital, Baltimore, MD 21287.

View larger version (72K): [in a new window]   Fig. 1A. —Normal and surgically altered retroperitoneum. Sm. bowel = small bowel, Duo. II = second portion of duodenum, Rt. K = right kidney, Lft. K = left kidney, Q. lumborum = quadratus lumborum. Drawing shows normal retroperitoneum.

View larger version (81K): [in a new window]   Fig. 1B. —Normal and surgically altered retroperitoneum. Sm. bowel = small bowel, Duo. II = second portion of duodenum, Rt. K = right kidney, Lft. K = left kidney, Q. lumborum = quadratus lumborum. Drawing shows that after right nephrectomy, right colon and right hepatic lobe occupy renal fossa. Second portion of duodenum and pancreatic head may assume more posterolateral position.

View larger version (83K): [in a new window]   Fig. 1C. —Normal and surgically altered retroperitoneum. Sm. bowel = small bowel, Duo. II = second portion of duodenum, Rt. K = right kidney, Lft. K = left kidney, Q. lumborum = quadratus lumborum. Drawing shows that after left nephrectomy, pancreatic tail assumes a more posterior position, approaching quadratus lumborum. Spleen shifts posteromedially. Caudal to pancreas, proximal jejunum and descending colon fill left renal fossa.

View larger version (120K): [in a new window]   Fig. 2A. —Locally recurrent renal cell carcinoma as seen in contrast-enhanced helical CT. CT scan of 46-year-old man with recurrent renal cell carcinoma who underwent left nephrectomy reveals enhancing mass (arrow) that invaded left psoas and quadratus lumborum muscles.

View larger version (124K): [in a new window]   Fig. 2B. —Locally recurrent renal cell carcinoma as seen in contrast-enhanced helical CT. CT scan of 41-year-old woman with recurrent renal cell carcinoma in left renal fossa shows enhancing mass (arrow) anteriorly displacing pancreatic tail. Note adult polycystic kidney disease.

View larger version (172K): [in a new window]   Fig. 2C. —Locally recurrent renal cell carcinoma as seen in contrast-enhanced helical CT. CT scan of 59-year-old man who underwent right radical nephrectomy for renal cell carcinoma several years earlier and who presented with back pain shows heterogenously enhancing recurrent tumor (arrows) in right adrenal bed.

View larger version (140K): [in a new window]   Fig. 3. —58-year-old man with left paraaortic lymphadenopathy occurring several years after left nephrectomy. Contrast-enhanced helical CT scan shows recurrent tumor (arrow) with peripheral contrast enhancement. Diagnosis was confirmed by imaging-guided percutaneous biopsy.

View larger version (156K): [in a new window]   Fig. 4. —64-year-old man who underwent right nephrectomy for renal cell carcinoma and developed cough and hemoptysis. He was afebrile, and results of coagulation studies were normal. Contrast-enhanced helical CT scan shows bilateral lower lobe metastases and left lower lobe air-space opacity near largest mass. Air-space process rapidly and completely resolved, indicating spontaneous hemorrhage. Note left coronary artery calcification.

View larger version (118K): [in a new window]   Fig. 5. —60-year-old man with advanced right renal cell carcinoma. Contrast-enhanced helical CT scan shows thickened, nodular interlobular septae forming polygonal arcades (arrow) in right lower lobe close to right hemidiaphragm, indicating lymphangitic carcinomatosis. Subcarinal and retroperitoneal nodal metastases were evident on other images.

View larger version (121K): [in a new window]   Fig. 6A. —Bone metastasis in renal cell carcinoma. Contrast-enhanced helical CT scan displayed at bone window settings in 55-year-old man who underwent prior nephrectomy for renal cell carcinoma, and who presented with diffuse bone pain, shows expansile lytic metastases (arrows) in sacrum and ilia.

View larger version (149K): [in a new window]   Fig. 6B. —Bone metastasis in renal cell carcinoma. Contrast-enhanced helical CT scan in 59-year-old man who underwent left nephrectomy for renal cell carcinoma, and who presented with back pain and weakness, reveals enhancing lytic metastasis (arrow) of left T12 pedicle with spinal canal encroachment. Patient was treated with surgery.

View larger version (128K): [in a new window]   Fig. 7. —57-year-old man with widely metastatic renal cell carcinoma. Contrast-enhanced helical CT scan shows innumerable hypervascular liver metastases. Note right pleural effusion.

View larger version (103K): [in a new window]   Fig. 8A. —72-year-old man with solitary liver metastasis 3 years after left radical nephrectomy for renal cell carcinoma. Case emphasizes importance of arterial phase imaging in detecting renal cell carcinoma metastatic to liver. (Reprinted with permission from [9]) Contrast-enhanced helical CT scan during arterial phase reveals markedly hypervascular mass (arrow) in medial segment of left lobe that indents gallbladder.

View larger version (120K): [in a new window]   Fig. 8B. —72-year-old man with solitary liver metastasis 3 years after left radical nephrectomy for renal cell carcinoma. Case emphasizes importance of arterial phase imaging in detecting renal cell carcinoma metastatic to liver. (Reprinted with permission from [9]) Contrast-enhanced helical CT scan during portal venous phase obtained 63 sec after A shows mass (arrow) to be nearly isodense compared with normal liver. Metastasis was confirmed at surgery.

View larger version (126K): [in a new window]   Fig. 9. —69-year-old man who underwent right nephrectomy for renal cell carcinoma 3 years earlier. Contrast-enhanced helical CT scan shows multiple masses in left kidney and left adrenal gland (arrow). Because renal lesions appeared synchronously on serial CT scans with adrenal mass and pulmonary mass (not shown), they were thought to represent metastases.

View larger version (84K): [in a new window]   Fig. 10. —85-year-old woman who complained of left scapular pain 10 years after nephrectomy for renal carcinoma. Contrast-enhanced helical CT scan shows enhancing mass (arrow) involving scapular spine. No other metastases were evident. Diagnosis was established at open biopsy.

View larger version (185K): [in a new window]   Fig. 11A. —Renal cell carcinoma metastatic to pancreas. Arterial phase contrast-enhanced CT scan in 63-year-old man who underwent left nephrectomy for renal carcinoma 7 years earlier shows enhancing mass (arrow) in tail of pancreas. Note surgical clips in left renal fossa. Solitary metastasis was confirmed on subsequent distal pancreatectomy. (Reprinted from [10])

View larger version (155K): [in a new window]   Fig. 11B. —Renal cell carcinoma metastatic to pancreas. Contrast-enhanced helical CT scan of 54-year-old man with previously resected left renal carcinoma who presented with palpable mass in right upper quadrant reveals large hypervascular mass (curved arrows) in head of pancreas, which, at endoscopy, was noted to have invaded second portion of duodenum. Numerous smaller metastases were present in pancreatic body and tail. CT scan also shows collateral vein (straight arrow) resulting from splenic vein obstruction by mass.

View larger version (136K): [in a new window]   Fig. 12. —75-year-old man with history of renal cell carcinoma metastatic to lungs. Contrast-enhanced helical CT scan displayed at lung window setting reveals unsuspected endobronchial nodule (arrows) in bronchus intermedius. Other lower lobe metastases are present.

View larger version (135K): [in a new window]   Fig. 13. —59-year-old man who had known lung and brain metastases from renal cell carcinoma 2 years after right radical nephrectomy. Contrast-enhanced helical CT scan shows uniformly enhancing metastasis (arrow) in right erector spinae muscle. Mass was palpable but not tender.

View larger version (131K): [in a new window]   Fig. 14. —45-year-old woman who underwent right radical nephrectomy for renal cell carcinoma 4 months earlier and complained of persistent nausea. Contrast-enhanced helical CT scan shows extensive enhancing mesenteric and paraaortic metastases (arrows). Note surgical clips in right renal fossa.

View larger version (127K): [in a new window]   Fig. 15A. —Renal cell carcinoma metastatic to small bowel. Unenhanced helical CT scan of 67-year-old man who had upper gastrointestinal bleeding, emesis, and renal insufficiency 6 years after right nephrectomy shows intraluminal mass (arrow) in second portion of duodenum. Endoscopic biopsy confirmed metastasis from renal cell carcinoma. Treatment was pancreaticoduodenectomy.

View larger version (100K): [in a new window]   Fig. 15B. —Renal cell carcinoma metastatic to small bowel. Contrast-enhanced helical CT scan of 44-year-old man who had prior resection of large right renal tumor and who had symptoms of intestinal obstruction reveals two small bowel metastases (arrows), the larger representing lead point of ileocolic intussusception. Both lesions, as well as omental and mesenteric metastases, were confirmed at surgery.

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