AJR 2001; 177:653-658
© American Roentgen Ray Society
Patterns of Recurrence in Renal Cell Carcinoma
Manifestations on Helical CT
John C. Scatarige1,
Sheila Sheth,
Frank M. Corl and
Elliot K. Fishman
1
All authors: Russell H. Morgan Department of Radiology and Radiological
Science, The Johns Hopkins Hospital, Baltimore, MD 21287.
Received December 22, 2000;
accepted after revision January 30, 2001.
Address correspondence to E. K. Fishman, Department of Radiology, The Johns
Hopkins Hospital, 601 N. Caroline St., JHOC Rm. 3254, Baltimore, MD
21287-0801.
Introduction
Helical CT is invaluable in characterizing renal masses and in the
preoperative staging of patients with suspected renal cell carcinoma. Equally
important, however, is the role of CT in monitoring patients with renal cell
carcinoma after nephrectomy. The accurate detection of recurrent disease
provides key prognostic information and assists the oncologist in making
treatment decisions involving either surgery or immunotherapy
[1].
In this pictorial essay, we review some important clinical aspects of renal
cell carcinoma, briefly discuss CT technique, and illustrate some common as
well as atypical manifestations of renal cell carcinoma metastasis that may be
encountered on postoperative CT surveillance.
Clinical Features of Recurrent Renal Cell Carcinoma
Knowledge of the mechanisms, risk factors, and clinical timing of recurrent
disease in surgically treated renal cell carcinoma can assist the radiologist
in understanding the patterns of recurrence observed on imaging.
Frequency and Mechanisms of Recurrence
Local recurrence occurs in about 5% of patients. It is associated with
incomplete resection of the primary tumor, positive surgical margins, and
regional lymph node metastasis
[2]. Distant metastases are
present at the time of diagnosis in up to 30% of patients
[1]. Among those with localized
disease who are treated surgically, 20-30% will eventually develop distant
metastasis [1,
3].
Dissemination occurs via lymphatic and hematogenous routes. Retrograde
collateral flow via the lumbar veins into the vertebral plexuses of Batson
appears to be particularly important in metastasis to the axial skeleton and
the brain [4].
Risk Factors for Recurrence
The surgical stage of renal cell carcinoma at the time of diagnosis is the
most important determinant in predicting local recurrence or distant
metastasis. Large tumors that invade locally or propagate as venous tumor
thrombus have higher rates of distant metastasis
[1]. Regional lymph node
metastases, a high Fuhrman grade on histopathology, and spindled (sarcomatoid)
tumor architecture also adversely influence prognosis
[1,
5,
6].
Timing of Recurrence and Metastasis
Distant metastases or local recurrence or both usually occur within the
first 6 years after surgery [2,
5]. Patients with positive
nodes at surgery relapse even sooner, generally within 3 years
[2]. Late recurrence is a
distinctive clinical aspect of renal cancer, observed in as many as 11% of
patients surviving 10 years or more after surgery
[3].
Helical CT Technique
Like the primary tumor, local recurrences and metastases are highly
vascular. Therefore, arterial phase scanning is essential for maximizing
lesion conspicuity. To facilitate detection of vascular liver metastases, the
abdomen and pelvis are scanned first, from the diaphragm to the symphysis
pubis, during the arterial phase of enhancement. Next, the chest is imaged
from the lung apices through the liver and remaining kidney. Because these
patients, as well as those with familial renal carcinoma or von Hippel-Lindau
disease, are at increased risk for additional renal primary carcinomas, the
remaining kidney must be carefully scrutinized on each follow-up CT.
Retroperitoneal anatomy is significantly altered after nephrectomy (Fig.
1A,1B,1C).
Small bowel and colon may migrate into the nephrectomy fossa. To help
differentiate nonopacified bowel from local recurrence, we routinely
administer 750 mL of oral contrast material 45-60 min before scanning.
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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.
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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.
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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.
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Common Patterns of Recurrence Revealed on CT
Local Recurrence in Renal Fossa
After nephrectomy, recurrent renal carcinoma appears as an enhancing mass
in the surgical site. The recurrence often involves the quadratus lumborum and
psoas muscles (Figs. 2A and
2B), and can displace or invade
nearby structures. The cephalic extent may reach the adrenal bed
(Fig. 2C) or may involve the
ipsilateral adrenal gland if the latter was spared at the time of nephrectomy.
Recurrent cancer after nephron-sparing surgery can be suggested when an
enhancing nodule develops in the wedge-shaped partial nephrectomy defect.
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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.
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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.
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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.
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Regional Lymphadenopathy
Lymph nodes close to the renal vascular pedicle are the most frequently
involved [4]
(Fig. 3) and represent an
important predictor for multifocal distant metastasis
[6].
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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.
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Distant Metastases
Renal carcinoma typically metastasizes to the following distant sites,
listed in order of descending frequency: lung (Figs.
4 and
5) and mediastinum, bone (Fig.
6A,6B),
liver (Figs. 7 and
8A,8B),
contralateral kidney or adrenal gland or both
(Fig. 9), and brain
[6,
7]. Multifocal metastases are
common. Pulmonary metastases occur in 50-60% of patients with distant disease
[1]. These metastases may be
hemorrhagic or involve the interstitial lymphatics (Figs.
4 and
5). Bone metastases are lytic,
are expansile, and favor the axial skeleton, particularly from T12 to the
pelvis [4] (Fig.
6A,6B).
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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Atypical Manifestations
Metastases occurring in unusual sites or developing many years after
nephrectomy are being recognized more frequently. An accurate diagnosis is
important because some isolated recurrences can be cured with surgical
excision.
Late Metastasis
Metastasis discovered 10 years or more after surgery is a well-recognized
clinical peculiarity [3]. Lung,
pancreas, bone, skeletal muscle, and bowel are the most frequent sites for
metastases [3,
7]
(Fig. 10). Surgical treatment
is often warranted.
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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.
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Pancreatic Metastasis
Metastases to the pancreas may be solitary or multiple and may occur many
years after nephrectomy [8]. In
contrast to primary ductal pancreatic adenocarcinoma, pancreatic metastases
from renal cell carcinoma are hypervascular (Fig.
11A,11B).
Surgical resection can improve the likelihood of patient survival
[8].
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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])
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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.
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Endobronchial Metastasis
These uncommon lesions can be detected incidentally or are discovered on
imaging or bronchoscopy in patients presenting with hemoptysis or atelectasis
(Fig. 12).
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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.
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Skeletal Muscle Metastasis
Most skeletal muscle metastases detected on helical CT are asymptomatic and
occur in patients with advanced disease. These metastases tend to enhance
uniformly. The erector spinae muscle is a favored site for skeletal muscle
metastases (Fig. 13).
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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.
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Peritoneal and Bowel Metastases
Locally recurrent renal carcinoma may directly invade the ascending or
descending colon. More advanced patterns of recurrence include peritoneal
carcinomatosis and mesenteric lymphadenopathy
(Fig. 14). Metastases to the
small bowel may produce gastrointestinal hemorrhage or intussusception (Fig.
15A,15B).
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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.
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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.
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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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Conclusion
The clinical course of renal cell carcinoma after nephrectomy is variable
and unpredictable. Contrast-enhanced helical CT is the ideal modality for
conducting postoperative surveillance in patients at risk for recurrent or
metastatic disease. Optimum care is rendered to these patients when
radiologists understand the unique clinical features of this neoplasm and are
familiar with the common and the atypical manifestations of recurrent
disease.
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Introduction
Clinical Features of Recurrent...
