Increased use of imaging has increased the detection of renal lesions most of which are simple cysts. Also a greater percentage of small renal lesions have been noted which has changed the therapeutic strategy towards renal lesions. CT and MRI findings are fairly classical for renal tumors. Initial diagnosis with IV urography or ultrasound may require further confirmatory testing.

• Computed tomography
  • Provides an excellent assessment of the parenchyma and nodal status. Thin slice images provide superior definition of smaller lesions. Good assessment of nodal status is provided. Tissue signature of fat allows diagnosis of AML. 3-D reconstruction now available
• Magnetic Resonance Imaging
  • Non ionizing radiation modality provides excellent demonstration of solid renal masses and is image test of choice to demonstrate extent of vena caval involvement with tumor. Useful in patients with renal insufficiency
• Ultrasonagraphy
  • Excellent in distinguishing cystic from solid masses.
  • 30-50% of patients >50 years will have renal cysts
  • Bosniak classification provides guidelines for cysts
    From the BJU International Mini Reviews: The Bosniak Classification of Renal Cystic Masses.
    • I [Simple cyst] 0%
    • II [Minimally complicated] 2-10% cancer risk
    • III [Indeterminate cyst] up to 50% cancer risk
    • IV [Cystic renal cell] up to 90% cancer risk
• Intravenous Urography
  • Starting point for hematuria evaluations
  • Abnormal findings require other imaging for conformation
  • Calcification pattern suggestive
    • Speckled or mottled, 90% cancer
    • Rim calcification 10-20% cancer
• Angiography
  • Generally supplanted by MRI angiography
  • Used for embolization of large lesions preoperatively
• Radionuclide Imaging
  • Most useful in detecting pseudo-masses
  • Tumors and cysts are photo-deficient areas
• Percutaneous biopsy
  • Generally not useful due to the high [30-50 percent] false positive rate
  • Some value in ruling out metastatic disease or lymphoma

References

• Bostwick DG, Eble JN: Diagnosis and classification of renal cell carcinoma. Urol Clin N Am 26:627-635, 1999.
• Caddeddu JA, Ono Y, Clayman RV, et al: Laparoscopic nephrectomy for renal cell cancer: Evaluation of efficacy and safety: A multicenter experience. Urology 52:773-777, 1998.
• Levy DA, Slaton JW, Swanson DA, Dinney CP: Stage specific guidelines for surveillance after radical nephrectomy for local renal cell carcinoma. J Urol 15:1163-1167, 1998.
• Montie JM: Lymphadenectomy for renal cell carcinoma. Semin Urol 7:181-185, 1989.
• Motzer RJ, Bander NH, Nanus DM: Renal-cell carcinoma. N Engl J Med 335:865-875, 1996.
• Novick AC: Renal-sparing surgery for renal cell carcinoma. Urol Clin North Am 20:277-282, 1993.
• Sagalowsky AI, Kadesky KT, Ewalt DM, Kennedy TJ: Factors influencing adrenal metastasis in renal cell carcinoma. J Urol 151:1181-1184, 1994.
• Skinner DG, Pritchett RT, Lieskovsky G, Boyd SD, Stiles QR: Vena caval involvement by renal cell carcinoma. Surgical resection provides meaningful long-term survival. Ann Surg 210:387-394, 1989.
• Sufrin G, Cashon S, Golio A, Murphy GP: Paraneoplastic and serologic syndromes of renal adenocarcinoma. Semin Urol 7:158-171, 1989.
• Yang JC, Topalian SL, Parkinson D, et al: Randomized comparison of high-dose and low-dose intravenous interleukin 2 for the therapy of metastatic renal cell carcinoma: An interim report. J Clin Oncol 12:1572-1576, 1994.

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