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Imaging Guidelines for Renal Tumors: Recommendations from the May 2010 Workshop

This document outlines essential imaging guidelines for the diagnosis and staging of renal tumors, particularly Renal Cell Carcinoma (RCC). Key modalities include ultrasound (US), computed tomography (CT), and magnetic resonance imaging (MRI). Specific recommendations are provided for further investigation of any abnormalities detected on ultrasound or intravenous pyelography (IVP) using CT with and without contrast, based on renal function. It discusses the use of imaging to differentiate between solid and cystic lesions, and offers guidance on biopsy and staging systems.

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Imaging Guidelines for Renal Tumors: Recommendations from the May 2010 Workshop

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  1. PRE-OP DIAGNOSIS Resident’s Renal Tumors Workshop May 2010

  2. IMAGING GUIDELINES for IMAGING • Any finding on US or IVP should be further investigated with CT (with and without contrast media, dep. on renal function) • Abdominal CT and MRI are recommended for the workup of patients with RCC and are the most appropriate imaging modalities for TNM classification prior to surgery • MRI may be reserved for locally advanced SOL, possibly venous involvement, renal insuffiency or allergy to IV contrast • Bone scan / brain CT are indicated only according to clinical or laboratory signs and symptoms

  3. IMAGING US • May differentiate cystic from solid lesion • Simple Cyst (vs. complicated one) • Unechoic • Thin wall • Posterior enhancement • Round / oval • Avascular

  4. IMAGING US • Not all hyper-echoic lesions are AML!!! • Small RCCs (<3cm) maybe hyperechoic and mimic AML • US may be modality of choice for follow-up in patients on surveillance • Doppler-US may help in assessment of vascularity within renal mass • Vascularity is strongly associated with RCC

  5. IMAGING CT • Accuracy for staging is 91% • Is a multi-phasic examination • CTU (3-phase) / 4-phase (for renal masses) • Unenhanced CT • Cortico-medullar phase • Nephrographic phase • Excretory phase

  6. IMAGING MRI • For small lesions (< 1cm) that can not be accurately diagnosed by other means • To differentiate complicated cysts (between Bosniac IIF and III) • For solid masses that enhancement can not determined by CCT • For pregnancy and F/U in young patients • Nphrogenic Systemic Fibrosis (NSF): results from deposits of gedolinium in soft tissues (when GFR <30cc/min)

  7. BENIGN LESIONS • Size does matter !!! • There is a positive correlation between mass size and malignancy potential • In cT1 overall 20-30% are benign • <3 cm = 25% • <2 cm = 30% • <1 cm = 44%

  8. BENIGN LESIONS • Prevalence • 70% oncocytomas • 18% AML • 4% papillary adenoma • 1% meta-nephric adenoma

  9. BIOPSY for DIAGNOSIS? • GUIDELINES for BIOPSY ? • INDICATIONS • Has a limited role • Maybe of help in differentiating primary lesion from metastatic disease

  10. STAGING SYSTEMS • ROBSON’s • TNM • MSKCC • UCLA

  11. RENAL CYSTS: CLASSIFICAION BOSNIAK’s CLASSIFICATION • Done on CT • I: Benign simple cyst, low attenuation (0-20 HU), no enhancement • II: few hairline septa, fine calcification, low or high attenuation but homogenous, non-measurable enhancement

  12. II

  13. RENAL CYSTS: CLASSIFICAION BOSNIAK’s CLASSIFICATION • IIF: multiple hairline septa, irregular wall, thick / irregular / nodular calcifications, high attenuation (>3cm, intrarenal), non-measurable enhancement • Can not be considered benign without due follow-up (@6 months, by CT or MRI, for 5 yrs)

  14. IIF

  15. RENAL CYSTS: CLASSIFICAION BOSNIAK’s CLASSIFICATION • III: thick wall / septa, multi-locular, measurable enhancement • hemorrhagic / infected cyst • Malignancy prevalence = 31-50%

  16. III

  17. RENAL CYSTS: CLASSIFICAION BOSNIAK’s CLASSIFICATION • IV: as III + enhancement of soft tissue component adjacent to or separate from the wall or septa • Malignancy prevalence = 80-100% • Growth rate is not correlated to grade

  18. IV

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