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Renal Cell Carcinoma: Diagnosis, Staging, and Surveillance

Chaan S. Ng1, Christopher G. Wood2, Paul M. Silverman1, Nizar M. Tannir3, Pheroze Tamboli4 and Carl M. Sandler1

1 Department of Radiology, Box 368, The University of Texas M. D. Anderson Cancer Center, 1515 Holcombe Blvd., Houston, TX 77030-4009.
2 Department of Urology, The University of Texas M. D. Anderson Cancer Center, Houston, TX.
3 Department of Medical Oncology, The University of Texas M. D. Anderson Cancer Center, Houston, TX.
4 Department of Pathology, The University of Texas M. D. Anderson Cancer Center, Houston, TX.


Figure 1
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  		Fig. 1A —Histopathologic slides of renal cell carcinoma (RCC). (H and E) Conventional clear cell RCC. Tumor shows large uniform cells with abundant cytoplasm that is rich in glycogen.

 

Figure 2
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  		Fig. 1B —Histopathologic slides of renal cell carcinoma (RCC). (H and E) Papillary RCC type I. Tumor papillae are lined by short cuboidal cells with basophilic cytoplasm. Nuclei are small with few inconspicuous nucleoli. Collection of foamy histiocytes is present in middle of lower half of image.

 

Figure 3
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  		Fig. 1C —Histopathologic slides of renal cell carcinoma (RCC). (H and E) Papillary RCC type II. Tumor shows papillae lined by columnar to pseudostratified cells that have striking eosinophilic cytoplasm.

 

Figure 4
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  		Fig. 1D —Histopathologic slides of renal cell carcinoma (RCC). (H and E) Chromophobe RCC. Note sheet of tumor cells with focal necrosis (upper left corner). Tumor cells have abundant pale flocculent cytoplasm, prominent cell membranes, perinuclear halos, and wrinkled nuclei.

 

Figure 5
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  		Fig. 2A —Schematic diagrams of TNM staging of renal cell carcinoma. (© 2008 The University of Texas M. D. Anderson Cancer Center) Stage T1 tumor < 7 cm.

 

Figure 6
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  		Fig. 2B —Schematic diagrams of TNM staging of renal cell carcinoma. (© 2008 The University of Texas M. D. Anderson Cancer Center) Stage T2 tumor > 7 cm.

 

Figure 7
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  		Fig. 2C —Schematic diagrams of TNM staging of renal cell carcinoma. (© 2008 The University of Texas M. D. Anderson Cancer Center) Stage T3a tumors involving perinephric fat (C) and adjacent adrenal gland (D).

 

Figure 8
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  		Fig. 2D —Schematic diagrams of TNM staging of renal cell carcinoma. (© 2008 The University of Texas M. D. Anderson Cancer Center) Stage T3a tumors involving perinephric fat (C) and adjacent adrenal gland (D).

 

Figure 9
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  		Fig. 2E —Schematic diagrams of TNM staging of renal cell carcinoma. (© 2008 The University of Texas M. D. Anderson Cancer Center) Stage T3b tumor involving renal vein or inferior vena cava (IVC) inferior to diaphragm.

 

Figure 10
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  		Fig. 2F —Schematic diagrams of TNM staging of renal cell carcinoma. (© 2008 The University of Texas M. D. Anderson Cancer Center) Stage T3c tumor involves IVC superior to diaphragm.

 

Figure 11
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  		Fig. 3A —CT reformations of bilateral renal tumors in 60-year-old woman. Large arrows indicate primary renal tumor. CT scan shows solid left renal mass (large arrow) and complex cystic right renal mass (small arrow).

 

Figure 12
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  		Fig. 3B —CT reformations of bilateral renal tumors in 60-year-old woman. Large arrows indicate primary renal tumor. Coronal multiplanar reformation (MPR) during arterial phase shows one left and two right renal arteries (small arrows).

 

Figure 13
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  		Fig. 3C —CT reformations of bilateral renal tumors in 60-year-old woman. Large arrows indicate primary renal tumor. Coronal maximum intensity projection during arterial phase shows bilateral tumors (large arrows) and renal arteries (small arrows).

 

Figure 14
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  		Fig. 3D —CT reformations of bilateral renal tumors in 60-year-old woman. Large arrows indicate primary renal tumor. Volume-rendered image during arterial phase also shows renal arteries (small arrows).

 

Figure 15
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  		Fig. 3E —CT reformations of bilateral renal tumors in 60-year-old woman. Large arrows indicate primary renal tumor. Coronal MPR during delayed phase shows inferior vena cava (large thin arrows) and left renal vein (arrowheads), renal collecting system, aorta, and renal arteries (small thin arrows).

 

Figure 16
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  		Fig. 4A —CT appearances of various cell types of renal cell carcinoma (RCC). Conventional clear cell RCC in 59-year-old woman. CT scans of TNM stage T1a tumor in corticomedullary and nephrogenic phases show typical hypervascularity of tumor (arrow, A) and subsequent washout (arrow, B).

 

Figure 17
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  		Fig. 4B —CT appearances of various cell types of renal cell carcinoma (RCC). Conventional clear cell RCC in 59-year-old woman. CT scans of TNM stage T1a tumor in corticomedullary and nephrogenic phases show typical hypervascularity of tumor (arrow, A) and subsequent washout (arrow, B).

 

Figure 18
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  		Fig. 4C —CT appearances of various cell types of renal cell carcinoma (RCC). Papillary RCC in 48-year-old man. CT scans of TNM stage T1a tumor in corticomedullary (C) and nephrogenic (D) phases show typical hypovascularity of tumor (arrow).

 

Figure 19
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  		Fig. 4D —CT appearances of various cell types of renal cell carcinoma (RCC). Papillary RCC in 48-year-old man. CT scans of TNM stage T1a tumor in corticomedullary (C) and nephrogenic (D) phases show typical hypovascularity of tumor (arrow).

 

Figure 20
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  		Fig. 4E —CT appearances of various cell types of renal cell carcinoma (RCC). Chromophobe RCC in 61-year-old man. CT scans of TNM stage T2 tumor in corticomedullary (E) and nephrogenic (F) phases show hypovascularity of tumor (arrow).

 

Figure 21
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  		Fig. 4F —CT appearances of various cell types of renal cell carcinoma (RCC). Chromophobe RCC in 61-year-old man. CT scans of TNM stage T2 tumor in corticomedullary (E) and nephrogenic (F) phases show hypovascularity of tumor (arrow).

 

Figure 22
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  		Fig. 4G —CT appearances of various cell types of renal cell carcinoma (RCC). Medullary RCC (large arrow) and adjacent paraaortic adenopathy (small arrows) in 36-year-old man. CT shows TNM stage T1b N1 tumor.

 

Figure 23
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  		Fig. 5 —Tumor involvement of perinephric fat in 72-year-old woman. CT scan shows tumor with associated perinephric nodularity (arrow). TNM stage T3a disease was confirmed on resection specimen.

 

Figure 24
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  		Fig. 6 —Metastases to regional lymph node (TNM stage N2) in 81-year-old woman. CT scan shows enlarged left paraaortic node (small arrows) and adjacent stage T1b papillary renal cell carcinoma (large arrow).

 

Figure 25
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  		Fig. 7A —Venous involvement of renal vein and inferior vena cava (IVC). CT scan in 45-year-old woman shows enhancing tumor thrombus in expanded left renal vein (large arrows) (TNM stage T3b) and IVC (small arrow).

 

Figure 26
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  		Fig. 7B —Venous involvement of renal vein and inferior vena cava (IVC). Thrombus in left renal vein extends to origin of renal vein at IVC on coronal contrast-enhanced MR image (arrows) (TNM stage T3b) in 68-year-old woman. Arrowheads indicate left renal tumor.

 

Figure 27
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  		Fig. 7C —Venous involvement of renal vein and inferior vena cava (IVC). Thrombus in expanded right renal vein extends to supradiaphragmatic IVC on coronal contrast-enhanced MR image (arrows) (TNM stage T3c) in 82-year-old woman. Note aorta and renal artery origins are also visible (arrowheads).

 

Figure 28
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  		Fig. 7D —Venous involvement of renal vein and inferior vena cava (IVC). "Salt-and-pepper" appearance of vascularized tumor thrombus (arrows) in expanded IVC on CT scan in 61-year-old woman.

 

Figure 29
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  		Fig. 8A —Metastatic disease (TNM stage M1). Note hypervascular nature of most metastases. Pulmonary metastases in 76-year-old man. CT scan shows typical well-defined "cannonball" nodules (arrows).

 

Figure 30
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  		Fig. 8B —Metastatic disease (TNM stage M1). Note hypervascular nature of most metastases. Mediastinal and hilar nodal metastases (arrows) in 68-year-old man are seen on CT scan.

 

Figure 31
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  		Fig. 8C —Metastatic disease (TNM stage M1). Note hypervascular nature of most metastases. Conventional radiograph shows typical lytic appearance of metastases (arrows) in 58-year-old woman.

 

Figure 32
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  		Fig. 8D —Metastatic disease (TNM stage M1). Note hypervascular nature of most metastases. CT scan shows lytic lesion in left iliac bone and associated hypervascular soft-tissue metastasis (arrows) in same patient as in C.

 

Figure 33
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  		Fig. 8E —Metastatic disease (TNM stage M1). Note hypervascular nature of most metastases. Hypervascular liver metastases (arrows) are seen on CT scan in 72-year-old man. Note that these must be differentiated from hemangiomas.

 

Figure 34
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  		Fig. 8F —Metastatic disease (TNM stage M1). Note hypervascular nature of most metastases. Metastases to left adrenal gland (arrows) in 76-year-old woman.

 

Figure 35
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  		Fig. 8G —Metastatic disease (TNM stage M1). Note hypervascular nature of most metastases. Metastases to skeletal muscle (arrows) in 64-year-old man.

 

Figure 36
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  		Fig. 8H —Metastatic disease (TNM stage M1). Note hypervascular nature of most metastases. Metastases to pancreas (arrows) in 76-year-old man.

 

Figure 37
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  		Fig. 9A —Local recurrence after nephrectomy as seen on CT. Postsurgical appearances in left nephrectomy bed (lower arrow) in 52-year-old man resolved at follow-up. Note associated surgical vascular clips (upper arrow).

 

Figure 38
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  		Fig. 9B —Local recurrence after nephrectomy as seen on CT. Local tumor recurrence is seen in left nephrectomy bed (arrows) in same patient as in A.

 

Figure 39
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  		Fig. 9C —Local recurrence after nephrectomy as seen on CT. Pitfall of unopacified small bowel is seen in left nephrectomy bed of 58-year-old man, which could be misinterpreted as adenopathy (large arrow) and local tumor recurrence (small arrow) without careful tracing of bowel.

 

Figure 40
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  		Fig. 9D —Local recurrence after nephrectomy as seen on CT. Follow-up CT scan in same patient as in C shows gas in bowel loops (large and small arrows).

 

Figure 41
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  		Fig. 10 —Metastatic bone disease in same 58-year-old woman as in Figures 8C and 8D. Bone scintigram shows uptake in left iliac bone, right rib, and right femur (arrows).

 

Figure 42
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  		Fig. 11A —CT appearances after partial nephrectomy in 55-year-old man. CT scan obtained 6 weeks after left partial nephrectomy shows low-density lesion (arrow) at surgical site that could be confused with mass lesion.

 

Figure 43
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  		Fig. 11B —CT appearances after partial nephrectomy in 55-year-old man. Six months after partial nephrectomy, note resolution of postoperative changes (arrow). Also note previous right nephrectomy.

 

Figure 44
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  		Fig. 12A —Local recurrence after cryoablation as seen on CT of 61-year-old man. Scan before ablation shows hypervascular tumor (arrow) adjacent to cyst.

 

Figure 45
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  		Fig. 12B —Local recurrence after cryoablation as seen on CT of 61-year-old man. Scan 2 months after ablation shows low-density lesion with minimal marginal enhancement, typical of postablation changes (arrow).

 

Figure 46
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  		Fig. 12C —Local recurrence after cryoablation as seen on CT of 61-year-old man. Local recurrence (arrow) is seen 18 months after ablation.

 

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