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MRI for Preoperative Staging of Renal Cell Carcinoma Using the 1997 TNM Classification: Comparison with Surgical and Pathologic Staging

¹ Department of Radiology/MRI UH-B2B311, University of Michigan Health System, 1500 E Medical Center Dr., Ann Arbor, MI 48109-0003.
² Present address: Department of Radiology, Abdominal Imaging Section, Hacettepe University Faculty of Medicine, Ankara, Turkey.
³ Department of Biostatistics, School of Public Health, University of Michigan Health System, Ann Arbor, MI 48109.
⁴ Department of Pathology, University of Michigan Health System, Ann Arbor, MI 48109.

View larger version (34K): [in a new window]   Fig. 1A. —Grading of tumor thrombus extension. Drawings show tumor thrombus limited to renal vein (RV) (level 0, A), in renal vein protruding into vena cava but extending 2 cm or less above renal vein (level I, B), extending more than 2 cm above renal vein but below intrahepatic vena cava (level II, C), extending into intrahepatic vena cava but below diaphragm (level III, D), and extending above diaphragm into right atrium (RA) (level IV, E).

View larger version (37K): [in a new window]   Fig. 1B. —Grading of tumor thrombus extension. Drawings show tumor thrombus limited to renal vein (RV) (level 0, A), in renal vein protruding into vena cava but extending 2 cm or less above renal vein (level I, B), extending more than 2 cm above renal vein but below intrahepatic vena cava (level II, C), extending into intrahepatic vena cava but below diaphragm (level III, D), and extending above diaphragm into right atrium (RA) (level IV, E).

View larger version (42K): [in a new window]   Fig. 1C. —Grading of tumor thrombus extension. Drawings show tumor thrombus limited to renal vein (RV) (level 0, A), in renal vein protruding into vena cava but extending 2 cm or less above renal vein (level I, B), extending more than 2 cm above renal vein but below intrahepatic vena cava (level II, C), extending into intrahepatic vena cava but below diaphragm (level III, D), and extending above diaphragm into right atrium (RA) (level IV, E).

View larger version (46K): [in a new window]   Fig. 1D. —Grading of tumor thrombus extension. Drawings show tumor thrombus limited to renal vein (RV) (level 0, A), in renal vein protruding into vena cava but extending 2 cm or less above renal vein (level I, B), extending more than 2 cm above renal vein but below intrahepatic vena cava (level II, C), extending into intrahepatic vena cava but below diaphragm (level III, D), and extending above diaphragm into right atrium (RA) (level IV, E).

View larger version (47K): [in a new window]   Fig. 1E. —Grading of tumor thrombus extension. Drawings show tumor thrombus limited to renal vein (RV) (level 0, A), in renal vein protruding into vena cava but extending 2 cm or less above renal vein (level I, B), extending more than 2 cm above renal vein but below intrahepatic vena cava (level II, C), extending into intrahepatic vena cava but below diaphragm (level III, D), and extending above diaphragm into right atrium (RA) (level IV, E).

View larger version (164K): [in a new window]   Fig. 2. —64-year-old man with renal cell carcinoma in right kidney. Axial spin-echo T1-weighted image (TR/TE, 420/18) shows large mass (arrow) in upper pole of kidney that extends through renal capsule into perinephric fat but not through Gerota's fascia (arrowheads). This tumor was correctly staged as T3a by both reviewers.

View larger version (145K): [in a new window]   Fig. 3. —37-year-old man with renal cell carcinoma in right kidney. Axial fast spin-echo T2-weighted image with fat saturation (TR/TE, 3870/98) shows 13.5-cm mass with contour nodularity in right kidney (straight arrows) and discontinuity of surrounding low-signal-intensity renal capsule (curved arrow). Both reviewers classified this as T3a tumor. Pathologic examination revealed tumor to be confined to kidney and to have no perinephric fat invasion.

View larger version (127K): [in a new window]   Fig. 4. —71-year-old woman with renal cell carcinoma in right kidney. Axial fast spin-echo T2-weighted image with fat saturation (TR/TE, 3220/98) shows 1.5-cm hyperintense retrocaval soft-tissue mass (arrow) displacing inferior vena cava (arrowhead). Mass was called metastatic node on MRI. This node was reactive on pathologic examination.

View larger version (176K): [in a new window]   Fig. 5A. —42-year-old man with renal cell carcinoma in right kidney. Axial spin-echo T1-weighted image (TR/TE, 300/20) (A) and T2-weighted image with fat saturation (4200/98) (B) show large mass in right kidney that was staged as T3a N0 M0 by both reviewers. No metastatic nodes were identified by either reviewer on MRI. Pathologic examination of resected specimen showed two large metastatic hilar lymph nodes (arrows) measuring 3 and 1.2 cm in short-axis diameters.

View larger version (168K): [in a new window]   Fig. 5B. —42-year-old man with renal cell carcinoma in right kidney. Axial spin-echo T1-weighted image (TR/TE, 300/20) (A) and T2-weighted image with fat saturation (4200/98) (B) show large mass in right kidney that was staged as T3a N0 M0 by both reviewers. No metastatic nodes were identified by either reviewer on MRI. Pathologic examination of resected specimen showed two large metastatic hilar lymph nodes (arrows) measuring 3 and 1.2 cm in short-axis diameters.

View larger version (157K): [in a new window]   Fig. 6. —43-year-old man with renal cell carcinoma in left kidney. Coronal late arterial phase gadolinium-enhanced 3D spoiled gradient-echo T1-weighted image (TR/TE, 5.7/2.1; flip angle, 12°) shows left upper pole mass with enhancing heterogeneous tumor thrombus extending into left renal vein (arrows) but not into inferior vena cava. This finding was confirmed at surgery. Lack of enhancement of infrarenal inferior vena cava gives false impression of thrombus on this early gadolinium-enhanced image.

View larger version (169K): [in a new window]   Fig. 7. —54-year-old man who presented with bilateral leg swelling and was referred for MRI for preoperative staging of renal mass in left kidney detected on CT scan obtained at another hospital. Coronal venous phase gadolinium-enhanced 3D spoiled gradient-echo T1-weighted image (TR/TE, 6.3/2.3; flip angle, 12°) shows large renal mass in left kidney with enhancing tumor thrombus extending above and below (arrowheads) short segment of uninvolved inferior vena cava. Note tumor thrombus extension through retroaortic renal vein (solid arrow) into inferior vena cava. Nonenhancing, low-signal-intensity bland thrombus is seen in inferior vena cava below tumor thrombus (open arrow). Tumor thrombus in proximal inferior vena cava extends to level of diaphragm (level III). These findings were confirmed at surgery.

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