Imaging, 23 (2014), 20110081

RENAL TRACT IMAGING

Imaging of renal masses and staging of renal tumours

A J BRADLEY, MRCP, FRCR and Y Y LIM, FRCS, FRCR
Radiology Department, University Hospital of South Manchester NHS Foundation Trust,
Manchester, UK
Summary
Renal masses are a common, often incidental finding on cross-sectional imaging.
Ultrasound can readily characterize a mass as solid or cystic.
The Bosniak classification is based on CT but can equally well be applied to MRI or

contrast-enhanced ultrasound.
CT is the main method for staging renal cell carcinoma (RCC), with MRI used in

specific indications, such as to assess the extent of venous involvement.

Most solid renal masses are assumed to be RCC, although approximately 20% of

masses under 3 cm will be benign.

The seventh edition of the American Joint Committee on Cancer TNM staging for

renal cancer has been presented.

An overview of the therapeutic options for renal cancer is discussed.

doi: 10.1259/img.20110081
2014 The British Institute of
Radiology

Cite this article as: Bradley AJ, Lim YY. Imaging of renal masses and staging of renal tumours. Imaging 2014;23:
20110081.

Abstract. Renal masses are commonly encountered in adult

radiological practice, with a range of appearances from entirely
cystic to solid. Characterization of more complex cystic masses
is a challenge, to which the now considerably refined Bosniak
classification has been applied. The Bosniak classification will
be discussed in detail, with the role of ultrasound, CT and MR
described. Dealing with the indeterminate masses presents an
additional challenge, which is greatly aided by dedicated CT
and MR protocols. Benign tumours of the kidney include
angiomyolipomas and oncocytomas. Prior to surgery, it is not
always possible to confidently define a lesion as benign,
although certain features, such as focal fat, are important.
Radiology plays a vital role in imaging renal cell carcinoma
(RCC). These tumours account for approximately 90% of all
malignant renal masses. The incidence of RCC is increasing,
which, at least in part, is a consequence of the exponential
increase in cross-sectional imaging. This has resulted in the
identification of many incidental tumours, which overall are of
a lower stage. The epidemiology, presentation and relevance of
the various surgical options will be reviewed. The imaging
modalities applied to staging will be discussed, with an
emphasis on multidetector CT. The TNM staging classification
in its most recently revised form is described, with discussion
of the challenges this presents to cross-sectional imaging. The
role of ultrasound, CT, MR and positron emission
tomography-CT in imaging RCC will be discussed. The use of
imaging-guided needle biopsy and percutaneous ablation in the
management of RCC is addressed. A brief mention is made of
Address correspondence to: Dr Alison J. Bradley. E-mail: alison.
bradley@uhsm.nhs.uk

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other cases of malignant renal masses, including transitional

cell carcinoma and lymphoma.
Masses of the renal parenchyma can be classified as
simple cystic, complex cystic, solid or indeterminate.
Benign or simple renal cysts are very common, with
around half the population over age 50 having simple
renal cysts.1,2 Prevalence increases with age, from ,10%
under 40 years to .60% over 80 years, and they are significantly more common in males than females.1 The
prevalence of renal cancer also increases with age, and
1015% of renal cancers are cystic in nature.2,3
Use of the Bosniak classification allows stratification of
cystic lesions into those that can be ignored, those that
need to be followed up and those that require urological
referral for consideration of removal.4,5 For all solid tumours, approximately 50% are detected incidentally,
usually at a smaller size and in an earlier stage than
symptomatic tumours.68 When considering masses ,4 cm,
6070% are now detected incidentally.911 Increased
incidental detection of small tumours has shown a rise in
the incidence of renal cancer, and consequently a rise in
both the number of treated cancers and 5-year survival
rate.12 However, approximately 20% of small renal
masses are benign,13,14 which complicates optimum management of such lesions. In the UK, all presumed renal
cancers are discussed at a multidisciplinary team meeting
with input from urologists, radiologists, histopathologists
and oncologists to optimize treatment decisions.
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A larger, solid lesion arising from the renal parenchyma almost always represents renal cell carcinoma
(RCC) and should be staged appropriately. The American
Joint Committee on Cancer staging of renal cancer was
revised in the seventh edition in 2010, to take into account
the prognostic features available from studies published
since the sixth edition in 2002.15

Cystic renal masses and the

Bosniak classification
Accurate characterization of cystic renal masses determines the management of such lesions and use of the
Bosniak classification enables this (Table 1).4,5 It was developed for CT but can equally be applied to MRI, or
ultrasound too, provided that contrast enhancement is
used.1618 The Bosniak classification is based on the following features as seen on CT: fluid density, wall and
septal thickness, enhancement, calcification and the position of the cystic mass within the kidney. An up-to-date
version is given in Table 1.

Ultrasound
Ultrasound is good for differentiating between cystic
and solid lesions, the hallmark of the cystic lesion being
an anechoic structure demonstrating strong posterior
acoustic enhancement. Provided that such a lesion has no
internal contents, and a sharply marginated posterior
wall, it can be categorized as Bosniak I or simple in nature.8 Although posterior acoustic enhancement is occasionally seen in solid lesions too, these will have
echogenic contents distinguishing them from cysts.
Harmonic imaging may be helpful in defining cystic
components, particularly in larger patients.19,20

Table 1. The Bosniak classification of renal cysts

Category Features

II

IIF

III

IV

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Simple cyst with a hairline-thin wall that does

not contain septa, calcification or solid
components. It has water attenuation and
does not enhance
May contain a few hairline-thin septa. Fine
calcification or a short segment of slightly
thickened calcification may be present in the
walls or septa. Sharply marginated uniformly
high-attenuating lesions (,3 cm) that do not
enhance are included
May contain multiple hairline-thin septa with
perceived enhancement. There may be
minimal thickening of the walls or septa,
which may contain calcification that may be
thick or nodular, but no measurable contrast
enhancement is present. Totally intrarenal
non-enhancing high-attenuating renal lesions
(.3 cm) are also included
Cystic mass with thickened irregular or smooth
walls or septa, in which measurable
enhancement is present at CT, MRI or
contrast-enhanced ultrasound
Clearly malignant cystic masses that can have all
of the criteria of category III, but also contain
distinct enhancing soft-tissue nodules

The Bosniak category II cyst is slightly complex with

one or two thin septa. The finding of more complex features on ultrasound, such as nodularity, calcification,
multiple septations and septal or wall thickening, warrants a CT (or MRI) scan for a more accurate assessment
of the lesion (Figure 1). Routine use of colour or power
Doppler for complex cysts can help to categorize complexity,21 such that any lesion showing flow within internal septa must be at least category III. The absence of
flow, however, cannot be taken as evidence of a lower
category. Use of contrast further clarifies, with accuracy
rates approaching those of CT.17,18

CT imaging technique
CT scanning plays the key role in the accurate assessment of complex cystic or solid lesions. To evaluate enhancement within a lesion, an unenhanced scan should
be performed followed by a scan in the nephrographic
phase (90120 s delay). The nephrographic phase is the
optimum phase to characterize renal masses.22 As there
is maximal and homogeneous renal parenchymal enhancement, this allows detection of renal masses, which
normally do not enhance to the same degree.23 The mean
attenuation value of the lesion should be obtained on the
unenhanced and post-contrast scan. Measurement should
be made on the thickest part of the septa or walls, using
the smallest possible region of interest (ROI) cursor. A
lesion is considered to be enhancing if there is an increase
of >20 HU between the pre- and post-contrast scans. An
increase of 1020 HU should be regarded as indeterminate, and further imaging is required for accurate
evaluation.24
For image review, multiplanar reconstruction (MPR) is
important to fully assess these lesions. Evaluation of the
volume data set, rather than just the axial images, has
been shown to reduce interobserver variation and result
in assignment of different Bosniak classifications, compared with using axial images alone.25 For optimal MPR,
thin slices of <1 mm are optimal. The same slice thickness, pitch and kilovolts should be used for both the preand post-contrast sequences to accurately compare
enhancement.
The diagnosis of lesions of Bosniak categories I and IV
is usually straightforward.
Bosniak I is a simple cyst, which can be categorized as
such, provided it is smooth and of homogeneous low
attenuation consistent with fluid (,20 HU). The presence
of an obviously enhancing soft-tissue nodule in a lesion
would make it a Bosniak category IV cyst, which is
a malignant cystic tumour.
The difficulty in categorizing a complex cyst lies in
differentiating between a Bosniak II and a Bosniak III
cyst.2,22,26 Appropriate characterization is important as it
determines management; surgical removal is considered
to be the standard of care for category III cysts, whereas
category II cysts can be ignored. The need for an option
between these two extremes of management has led to
the development of Category IIF (F represents followup).5 A Bosniak IIF cyst is more complex than a Bosniak
II cyst, for example with an increased number of thin
septa, or with minimal enhancement of the septa or walls
(perceived but not measurable on the ROI cursor). Calcification may be seen and appear slightly thick and
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Imaging of renal masses

parameters both pre- and post-gadolinium imaging, the

signal intensities will be comparable. An increase of
.15% on the post-contrast images can be taken to signify
enhancement. Ho et al31 found the mean enhancement of
50 renal tumours to be 97% or more, whereas in 50 renal
cysts it was ,5%. By using a threshold of 15%, all
tumours were identified. Subtraction of the pre- from the
post-contrast sequences will show signal void within
non-enhancing lesions or portions of lesions.32 Thus, any
residual signal on the subtracted images represents enhancing tissue. These should be performed in end expiration to allow accurate co-registration.23,33
MRI sequences should include axial dual echo in-phase
and opposed-phase T1 weighted (T1W) gradient recalled
echo, fat-saturated coronal T2 weighted (T2W) imaging
and fat-saturated, preferably three-dimensional T1W preand post-gadolinium imaging.34 The phases of enhancement are the same as seen with CT, thus cortico-medullary
phase will occur approximately 30 s after dynamic injection,
and parenchymal phase around 2 min after injection.
MRI has been shown to have similar diagnostic accuracy to CT in the characterization of renal cysts.16,30 It is
particularly effective in detecting blood products, although it should be noted that haemorrhage is not an
indication of malignancy within a cyst.23 In some cases,
MRI may depict additional septa, thickening of the walls
or enhancement within a complex cystic lesion. This
can lead to a change in management owing to an

Figure 1. (a) The septa within this complex renal cyst are
well seen on the ultrasound, but this cannot characterize the
lesion adequately. (b) The septa show measurable enhancement (white arrow) on the fat-saturated contrast-enhanced
MRI, consistent with Bosniak III status.

nodular but is not a feature of malignancy 27 (Figure 2).

Hyperdense cysts (.20 HU) can be categorized as II,
provided that they show a diameter ,3 cm, rounded
shape, sharp margins, homogeneous density and no
enhancement.28,29 Those lesions that fall outside these
parameters are now placed in the IIF category and thus
followed up (Figure 3).
Bosniak category III cysts are those with thickened
septa or walls, which show measurable enhancement
(enhancement that is detected by the ROI cursor over the
solid elements) (Figure 1).

MRI technique
The superior contrast resolution offered by gadoliniumenhanced renal MRI is helpful in further characterizing
lesions that have indeterminate enhancement (1020 HU)
on CT scan, or in patients unable to have iodinated contrast
medium.30,31 However, the risk of nephrogenic systemic
fibrosis needs to be considered in patients with end-stage
renal failure, in whom gadolinium products are ideally
avoided.32
Enhancement can be difficult to assess on MRI, but
signal intensity within a manually drawn ROI can be
measured in the same manner as on a CT scan. Provided
that the sequences have been obtained with the same
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Figure 2. (a) Pre- and (b) post-contrast axial CT. Two hypoattenuating lesions are seen on CT, one posterior to the right
kidney, which appears simple in nature. That in the left lower
pole contains a focus of calcification (black arrow), and fine
enhancement within a septum, consistent with a Bosniak
category II cyst. This does not require follow-up.

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A Bradley and YY Lim

assurance that a lesion is benign, but there are good

reports of success within the literature by proponents of
this technique.2,36

Benign renal masses

Figure 3. (a) Post-contrast CT scan. A small cyst in the lower

pole of the left kidney was thought to contain at least one
septum (black arrow). (b) At least two septa are seen on the
T2 weighted coronal MRI, owing to the superior contrast
resolution. The cyst was reported to be Bosniak III.

upgrading of the lesion.16,30 The disadvantage of MRI is

the inability to detect calcification, which is part of the
Bosniak4 classification, although a retrospective analysis
showed that even quite coarse calcification within a lesion
is not associated with an increased risk of malignancy.27

Management
Category I and II lesions require no follow-up. Category III and IV patients are referred for consideration
of surgical removal, as studies have shown malignancy
rates of 59.081.8%, and up to 100%, respectively.22,35,36
Follow-up is recommended for Bosniak IIF lesions.
The time interval required to definitively diagnose
a renal mass as benign is not known.5,8 Some authors
recommend 5 years follow-up, although there appears to be
no rationale for choosing this time interval.5,8,19
A suggested follow-up regimen for IIF lesions, which
we use at our institution, is imaging at 6, 12, 24 and 36
months from baseline, with comparison with baseline
imaging on each occasion.37 If comparison is only made
with the previous attendance, then subtle changes may be
missed. At 36 months, a decision can be made regarding
further imaging. The patients symptoms, age, presentation and degree of anxiety about an indeterminate
renal mass must be taken into consideration, when proposing follow-up of an IIF lesion.
The authors do not biopsy complex cystic lesions, because of the risks of undersampling, leading to false
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Angiomyolipoma
The demonstration of macroscopic fat within a renal
lesion on a CT scan is diagnostic of an angiomyolipoma
(AML),38 a benign hamartoma or choristoma that contains fat, smooth muscle and blood vessels in variable
proportions (Figure 4). These can be multiple in patients
with tuberous sclerosis. Lesions .4 cm are at risk of
haemorrhage, and intervention (removal or embolization) should be considered at this size.39 Approximately
4.5% of AMLs do not demonstrate macroscopic fat on CT
or MRI, otherwise known as minimal fat AML.40 Although
studies have shown that AMLs demonstrate homogeneous high attenuation on unenhanced CT scan40 with
homogeneous and prolonged enhancement on contrastenhanced scans,41 these findings are not specific enough
to make a confident diagnosis.24,42
Chemical shift MRI techniques utilize the presence of
fat and water within the same voxel. Fat protons process
at a lower frequency than water protons, and this results
in loss of signal within a mass on opposed-phase gradient
echo MRI, compared with the in phase. This effect can be
evident macroscopically or calculated by measuring the
signal change by the ROI cursor.43 This signal loss can be
seen in minimal fat AML; however, it has also been
reported in RCC sufficiently frequently to prevent diagnostic use (owing to small amounts of intracellular
lipid).31,44 More reliable is the presence of the India ink
artefact, seen as a black line at the interface between fatcontaining and water-containing structures. The India ink
artefact will be seen at the interface between an AML and
the renal cortex, but not at the interface with perinephric
fat.39,44
Oncocytoma
An oncocytoma is the commonest solid benign
renal tumour accounting for approximately 5% of all renal
masses45 and approximately 50% of non-RCC small

Figure 4. Axial nephrographic phase post-contrast CT scan

showing an 8-cm-diameter angiomyolipoma in the lower
pole of the left kidney (black arrows). At this size, there is
a risk of bleeding, and embolization or surgical removal
should be considered.

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Imaging of renal masses

activity on 18-fludeoxyglucosepositron emission tomography (18F-FDG-PET) has been documented.48

Multilocular cystic nephroma

Multilocular cystic nephromas are rare benign tumours
of uncertain cause. Approximately two-thirds present in
a predominantly male, paediatric population, aged between 3 months and 2 years. The other cohort is seen in
a predominantly female population in the fifth and sixth
decades of life. Ultrasound typically demonstrates
a complex cystic mass with thin dividing septations, although a solid mass component may be seen. CT demonstrates hyperattenuating septations that typically
enhance less than RCCs.49 The appearance of these
lesions puts them into Bosniak category III (Figure 1).

Malignant renal masses

Epidemiology
RCC accounts for 9095% of all primary malignant
tumours of the kidneys in adults. Less common causes
include primary renal lymphoma and transitional cell
carcinoma. Metastatic deposits in the kidney should always be considered in patients with a known primary
located elsewhere, especially bronchial carcinoma and
lymphoma.
Table 2. The American Joint Committee on Cancer TNM
staging for renal cell cancer, seventh edition

Figure 5. (a) Axial CT scan of a left T1a renal cell carcinoma

(white arrow). (b) Axial CT following partial nephrectomy
shows minor residual soft-tissue stranding at the site of the
resection.

Tx
T0
T1
T1a
T1b

resected masses in surgical series.9,13,46 Although described

as classically having a central stellate scar, or spoke wheel
pattern of enhancement on CT, this is found only in a
small proportion of cases; oncocytoma cannot be reliably
distinguished from RCC on imaging alone.47 Intense

T2
T2a
T2b
T3

T3a

T3b
T3c

T4

Figure 6. The primary left renal tumour was found to be

confined to the kidney at open nephrectomy (T Stage 2a).
Note the small round para-aortic node (black arrow), which
shows heterogeneous enhancement similar to the primary
tumour (N1).

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Nx
N0
N1
M0
M1

Primary tumour cannot be assessed

No evidence of primary tumour
Tumour #7 cm in greatest dimension, limited to
the kidney
Tumour #4 cm in greatest dimension, limited to
the kidney
Tumour .4 cm but #7 cm in greatest dimension,
limited to the kidney
Tumour .7 cm in greatest dimension, limited to
the kidney
Tumour .7 cm but #10 cm in greatest
dimension, limited to the kidney
Tumour .10 cm in greatest dimension, limited to
the kidney
Tumour extends into major veins or perinephric
tissues but not into the ipsilateral adrenal
gland and not beyond Gerotas fascia
Tumour grossly extends into the renal vein or its
segmental branches, or tumour invades
perirenal and/or renal sinus fat but not beyond
Gerotas fascia
Tumour grossly extends into the vena cava below
the diaphragm
Tumour grossly extends into the vena cava above
the diaphragm or invades the wall of the vena
cava
Tumour invades beyond Gerotas fascia
(including contiguous extension into the
ipsilateral adrenal gland)
Regional nodes cannot be assessed
No regional lymph node metastasis
Metastases in regional lymph node(s)
No distant metastases
Distant metastases

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Table 3. Updates included in the American Joint Committee on Cancer TNM staging for renal cell cancer, seventh edition
(1) The introduction of the T2b category for tumours confined to the kidney but measuring .10 cm
(2) Tumours involving the renal vein but not the inferior vena cava are now T3a (previously T3b). T3a would also include
invasion of renal sinus fat and perinephric fat
(3) Tumours extending into the ipsilateral adrenal gland are now T4 disease
(4) N1 category for regional lymph node metastases (previously N2 for more than one regional node)

In England, RCC accounts for 3% of all cancers seen in

males and 2% of all cancers seen in females. It is the 8th
most common tumour in males and 14th most common
in females. It is a tumour associated with increasing age
and is rarely seen in those less than 40 years old. About
40% of tumours are confined to the kidney, with no evidence of renal vein involvement. Approximately onequarter of RCCs present with distant metastatic disease.50
Across the world there has been an increase in the
reported incidence of this tumour, although some of this
is thought to be secondary to increased detection of incidental tumours by medical imaging.12 It is much more
common in Eastern European countries than in the UK.
Survival rates have been increasing, although this could
be due to early detection of incidental tumours, with
a degree of lead time bias. 5-year survival rates in the UK
are just under 50%, owing to those presenting with
metastatic disease having very poor outcomes.
Risk factors include severe obesity, heavy tobacco
smoking, the analgesic phenacetin (now banned in
Europe), hypertension and end-stage renal disease.51
Patients who develop acquired cystic disease after
many years on dialysis have a 36 times increased risk of
developing RCC, which can be multiple. Hereditary renal
cancers account for approximately 4% of the total; Von
HippelLindau (VHL) is the most commonly recognized,
as 3045% of patients with the VHL gene mutation will
develop renal cancer during their lifetime. VHL patients
who develop cancer almost always have other manifestations of the disease, for example renal cysts. 12% of
patients with tuberous sclerosis will develop renal cancers. Hereditary papillary renal cancer and BirtHogg
Dube syndrome are other associations. A hereditary
cancer syndrome should be considered in patients with
multiple bilateral renal tumours who present much earlier than the sixth and seventh decades.52,53

imaging characteristics, for example clear cell RCC

enhances more avidly and is more likely to show heterogeneous enhancement than papillary or chromophobe
types.54 Kim et al55 measured enhancement of renal
tumours in the cortico-medullary phase and found that
clear cell RCC enhanced to a mean of 149 HU, whereas
papillary RCC had a mean of 91 HU. As a further potential discriminatory feature, papillary RCC tends to be
hyperattenuating relative to the renal cortex on unenhanced CT.42
Clear cell RCC is frequently hyperintense on T2W
imaging and shows strong, often heterogeneous enhancement post gadolinium. Papillary RCC is often
hypointense on T2W imaging and has low-level homogeneous enhancement post contrast.34,42 These features
are useful for distinguishing between the types; however,
management depends upon the TNM stage, not the histological type.51 MRI has been shown to have similar
accuracy to CT scan in the diagnosis and staging
of RCC.30,56

Presentation
The classical clinical presentation of the triad of palpable mass, frank haematuria and flank pain is rarely
seen now, owing to the inexorable rise in incidentally
detected tumours.68 More tumours are now detected
incidentally than present symptomatically, leading to an
increased number of earlier stage tumours.911 Systemic
upset, including pyrexia, weight loss, thrombocythaemia
and hypercalcaemia are occasionally seen. Involvement
of the inferior vena cava can lead to pulmonary emboli,
oedema and BuddChiari syndrome. Metastases to bone
and brain usually present symptomatically.

Imaging renal cell carcinoma

Clear cell carcinoma accounts for approximately 70%
of renal cancers, papillary 1015% and chromophobe
411%.34 Different types of RCC will have different CT
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Figure 7. (a) Axial and (b) coronal CT scan of bilateral renal

masses in a 42-year-old male with haematuria. There is
invasion of the renal vein on the right (black arrow), and
involvement of the renal sinus bilaterally. TNM stage is T3a.

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Imaging of renal masses

Positron emission tomography-CT

The role of 18F-FDG-PET-CT imaging has yet to be
established in the setting of RCC. 18F-FDG is excreted in
the urine and therefore uptake in renal tumours is
masked. It has been demonstrated to be of only modest
diagnostic value in smaller studies, as renal tumours
demonstrate variable uptake of 18F-FDG.57,58 It possibly
has a role in defining bone metastases.

Staging
The TNM classification (Table 2) is the standard. This
has undergone several revisions over the years, the last in
January 2010, and is currently in its seventh edition. The
changes were made to reflect cancer-specific survival as
documented by several studies published since the sixth
edition.15 A summary of the changes is given in Table 3.
A higher stage is considered to predict a worse outcome,
although this is not always borne out in practice.59 A
number of predictive tools have been developed to use
in conjunction with TNM staging. The University of
California Los Angeles Integrated Staging System60 and

Figure 8. (a) Axial CT scan. Heterogeneously enhancing

tumour is extending through the expanded left renal vein
into the inferior vena cava (IVC) (black arrows). Note the left
renal tumour and enlarged collateral vessels medial to the
left kidney. (b) Coronal reconstruction demonstrates suprahepatic extension of the IVC thrombus (white arrows). TNM
stage is T3c.
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the Mayo Clinic stage61 consider other factors including

overall health, Furhman grade of the tumour (14, where
4 is the most aggressive histological pattern) and necrosis
score, in addition to size and stage.

T stage
Stages T1T2 describe those tumours that are confined
to the renal capsule. The classification of T1 into two size
designations aids the decision-making process when
choosing nephron-sparing therapies over more radical
surgery (Figure 5). T2 has also been subdivided into T2a
and b on the basis of size; the T2b category is for tumours
.10 cm but confined to the kidney (Figure 6). Determining the presence of Stage T3a disease (extension to
perinephric tissue) can be diagnostically challenging. Inflammatory changes surrounding the tumour can mimic
tumour extension, and the presence of a secondary
pseudocapsule can give the impression of an intact capsule, when in fact there is invasion.62,63 Therefore,
multidetector CT (MDCT) is not entirely reliable in determining perinephric invasion, but is probably the best
modality with reported 96% sensitivity, 93% specificity
and 95% accuracy.64,65 The role of MR in staging renal

Figure 9. (a) Axial fat-saturated post-gadolinium MRI. There

is lack of a fat plane between the large left upper pole renal
cell carcinoma and the spleen (white arrow), suspicious of
direct splenic invasion. (b) On ultrasound (performed to
biopsy the tumour), the splenic invasion is more obvious.
Stage T4.
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A Bradley and YY Lim

tumours is relatively limited, as it has not been proven to

be any more effective than MDCT in demonstrating local
tumour extent, with a reported staging accuracy of
8091% for T3a disease.66,67 Involvement of the main renal
vein or one of its intrarenal tributaries is now reclassified
as T3a disease, differentiating it from extension into the
vena cava (Figure 7). Tumour thrombus level has been
demonstrated to be an independent predictor of survival,
and studies support the changes made to the TNM staging
with regard to venous extension.6870
The presence of tumour thrombus above or below the
diaphragm determines Stage T3b vs T3c, which is of great
importance in planning surgery. MR has developed
a role as the modality of choice to define the extent of
tumour thrombus, having previously been demonstrated
to be superior to CT.71 However, two recent small studies
comparing modern MDCT against MRI found little difference in the ability of the two modalities to stage tumour
thrombus.72,73 In one of these studies, two independent
readers had accuracies of 7278% for MDCT vs 7688% for
MR72 (Figure 8).
Contiguous invasion of the adrenal gland from upper
pole renal tumours has been shown to have a significantly worse survival, with prognosis similar to stage pT4
disease.7476 This has led to the change in classification
from T3a to T4 for contiguous adrenal invasion. T4
tumours are also defined by their transgression of
Gerotas fascia. Smooth margins with an adjacent organ
usually indicate lack of invasion, whereas an irregular
margin is suspicious (Figure 9). An overview of the T
staging is shown in Figure 10.

N stage
The N2 category has been removed, and any number
of regional nodes is now classed as N1 (Figure 6). Nonregional nodes are M1. 1015% of patients have regional
nodal involvement without distant metastases.77 Crosssectional imaging modalities are limited in their ability to

stage nodal disease, as they rely predominantly on size

criteria. The problem lies in the high false-positive
rate (.50%) when using the standard criteria of short
axis diameter .1.0 cm.63 Therefore, patients should not be
denied surgery purely on the basis of enlarged nodes.
Attempts to adopt 18F-FDG-PET imaging to perform this
staging task have not shown the promise seen with other
neoplastic diseases.57,58

M stage
Metastases most commonly occur in lungs, bone, brain
and liver in that order.63 MDCT is the established modality for detecting metastatic disease, with 18F-FDG-PET
not showing sufficient reliability for RCC57,58 (Figure 11).

Follow-up imaging after resection of renal

cell carcinoma
Recurrent or metastatic disease is common in larger
tumours, those with an advanced stage at presentation
and those with a higher histological (Furhman) grade.
Metastatic disease develops in about one-third of patients
after radical nephrectomy, usually within 23 years of
surgery, with lungs being the most common site.78 Postoperative surveillance is recommended in at-risk patients,
although there is no consensus amongst UK urologists
regarding how this is done. CT scan of the thorax and
abdomen is advised in patients following nephron-sparing
surgery or T2 tumours and above with the following
frequency: 6 monthly for 2 years, then annually for
2 years. This seems sensible, as this will capture most
relapses.78,79 Patients with bony or brain metastases are
usually symptomatic; thus, routine follow-up by bone
scintigraphy and CT head is not required.

The role of percutaneous biopsy

Focal renal biopsy is a safe and effective procedure,
with a low complication rate, whether performed by

Figure 10. Diagram of TNM seventh edition staging of renal cancer ( University Hospital of South
Manchester 2011). (a) Stage T1a.
Tumour ,4 cm (T1b tumour .4 but
,7 cm). (b) Stage T2a. Tumour .7
but ,10 cm (T2b tumour .10 cm,
confined to the kidney). (c) Stage
3a. Tumour has breached the renal
capsule, involving perinephric fat.
(d) Stage 3b. Tumour thrombus is
in the renal vein and inferior vena
cava (IVC) below the diaphragm.
(e) Stage 3c. Tumour thrombus in
the IVC has extended above the
diaphragm. (f) Stage 4. Involvement of the ipsilateral adrenal
gland by tumour.

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Imaging 2014, 23, 20110081

Imaging of renal masses

ultrasound or CT guidance. The theoretical risk of seeding the track with tumour cells has proven to be
unfounded.80,81
A number of removed small renal masses are found to
be benign (around 20%),9,13,14 and costbenefit analysis
has shown that pre-treatment biopsy will avoid unnecessary and expensive surgery in a sizeable minority
of patients.82 The authors do not biopsy complex cystic
lesions, because of the risks of undersampling leading to
false assurance that a lesion is benign, but there are good
reports of success within the literature by proponents of
this technique.2,36
Parenchymal masses that remain indeterminate on
imaging assessment may require percutaneous biopsy
prior to surgical intervention.

Management of renal cell carcinoma

Recent recommendations from the American College
of Radiology advise intervention for masses .3 cm, and
observation for masses ,1 cm until they exceed 1.5 cm.19
Options for the small presumed renal cancer ,3 cm include active surveillance, ablation or surgery. The management chosen will reflect the patients attitude to risk,
comorbidities and local services available.

Figure 11. (a, b) Axial CT scan in a patient with metastatic

renal cell cancer. Enlarged posterior mediastinal and hilar
nodes are apparent (white arrows). Small pulmonary nodules
are seen on the mediastinal windows, but become more
apparent on the lung window in (b).

birpublications.org

Figure 12. CT urogram demonstrated non-excretion from

the right kidney with loss of the renal sinus fat and a small
retrocaval node (black arrow). Retrograde ureteroscopy and
biopsy revealed transitional cell carcinoma.

Approximately 20% of solid lesions ,4 cm are benign;

the smaller the mass, the more likely it is to be
benign.13,14 This has led to monitoring of the growth rate
of such lesions by serial ultrasound, CT or MR examinations performed at 6- or 12-month intervals. Follow-up
should be by the same modality to avoid errors in
measurement of size.24 Active surveillance for a period
of time will determine which patients will require
intervention.
Partial nephrectomy (nephron-sparing surgery) is considered as the standard of care for T1a tumours, as the
long-term incidence of renal insufficiency is less than after radical nephrectomy83 (Figure 5). Partial nephrectomy
can be performed open or laparascopically, with equivalent efficacy, although recovery (and hence length of
stay in the hospital) is shorter with the laparoscopic
technique.8386
Thermal ablation with either radiofrequency or cryotherapy is becoming an attractive option for T1a tumours
in patients with comorbidities that prevent surgical removal, with low complication and recurrence rates.87,88
These minimally invasive procedures can be performed
either with CT guidance or laparoscopically with ultrasound guidance. A recent meta-analysis slightly favours
cryotherapy as the more efficacious technique, having
fewer complications and a lower recurrence rate than
radiofrequency ablation.89
Radical open nephrectomy is generally reserved for
T34 disease, with laparoscopic nephrectomy preferred in
T1b and T2 disease.86 Supradiaphragmatic (level 3) tumour thrombus extension would involve a combined
thoraco-abdominal approach. Radiotherapy is not effective for metastatic RCC, but immunotherapy with interferon a and interleukin 2 combined results in modest
response rates. More recently, tyrosine kinase inhibitors,
which inhibit both angiogenesis and tumour cell
growth, are being used as adjuvant chemotherapy, and
increasingly as first-line therapy in metastatic disease.
Most experience is with sunitinib, which has demonstrated a higher response rate and prolonged progressionfree survival compared with interferon a.90 Second-line
agents include temsirolimus and sorafenib.91,92
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A Bradley and YY Lim

Other malignant renal masses

In a patient with a known primary malignancy elsewhere, metastasis should be considered especially if there
are multiple bilateral renal masses. These are often poorly
defined and infiltrate the renal parenchyma.24 Renal lymphoma most commonly presents as multiple, poorly enhancing bilateral renal masses.93 Patients with renal
lymphoma are usually symptomatic and often have other
sites of nodal enlargement. Transitional cell cancer (TCC)
of the upper tracts is much less common than renal cancer,
accounting for about 10% of renal malignancies, and usually is symptomatic, presenting with haematuria. Unless
large or infiltrating the renal parenchyma, it can be difficult
to detect without excretory-phase CT, where it is seen as
a filling defect within the opacified collecting system.94
Advanced TCC extends into the renal parenchyma in an
infiltrating pattern that distorts the normal renal architecture although the renal shape is preserved94 (Figure 12).

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