G e n i t o u r i n a r y I m a g i n g • R ev i ew

Ng et al.
Diagnosis and Staging of Renal Cell Carcinoma

Genitourinary Imaging
Review

Renal Cell Carcinoma: Diagnosis,

Staging, and Surveillance
Chaan S. Ng1 OBJECTIVE. This educational review focuses on the staging and radiologic evaluation of
Christopher G. Wood2 renal cell carcinoma. It includes discussion of the epidemiology, pathology, and therapeutic
Paul M. Silverman1 options of renal cell carcinoma and the implications for radiologic follow-up.
Nizar M. Tannir 3 CONCLUSION. The incidence of renal cell carinoma has been increasing. Imaging
Pheroze Tamboli 4 plays a central role in its detection, staging, and treatment evaluation and follow-up.
Carl M. Sandler 1

R
American Journal of Roentgenology 2008.191:1220-1232.

enal cell carcinoma (RCC), the laparoscopic and nephron-sparing approach-

Ng CS, Wood CG, Silverman PM, Tannir NM,
Tamboli P, Sandler CM
Keywords: imaging, renal cell carcinoma, staging
DOI:10.2214/AJR.07.3568
Received December 20, 2007; accepted after revision
April 10, 2008.
C. G. Wood is a consultant for Pfizer, Inc.; Antigenics,
Inc.; Bristol-Myers Squibb; Ethicon, Inc.; and Bayer
Healthcare.
1
Department of Radiology, Box 368, The University of
Texas M. D. Anderson Cancer Center, 1515 Holcombe
Blvd., Houston, TX 77030-4009. Address correspon-
dence to C. S. Ng (cng@mdanderson.org).
2 such as polycythemia secondary to excessive
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.
CME
The article is available for CME credit.
See www.arrs.org for more information.
AJR 2008; 191:1220–1232
0361–803X/08/1914–1220
© American Roentgen Ray Society
eighth most common malignan-
cy affecting adults, accounts for
between 3% and 4% of new can-
cer cases in the United States. It is the sev-
enth most common cancer in men and the
ninth most common in women [1]. We now
know that RCC actually represents a family
of related disorders with distinct cytogenetic
and immunohistochemical properties that
have differing prognoses, imaging character-
istics, and potential morbidities.
The classic clinical presentation of flank
pain, hematuria, and a palpable flank mass is
comparatively uncommon (5–10% of cases).
However, clinical symptomatology may be
quite nonspecific—for example, anorexia, tired­
­ness, weight loss, or fever of unknown origin
[2]. Other presentations include varicocele for-
mation (from tumor thrombus in the left renal
vein or the inferior vena cava [IVC]) and dis-
seminated malignancy. RCC may also present
with a variety of paraneoplastic syndromes,
secretion of erythropoietin, hypercalcemia
secondary to factors regulating calcium, and
hepatic dysfunction (Stauffer syndrome). Inci-
dentally detected tumors in asymptomatic indi-
viduals have been steadily increasing with the
dissemination of imaging techniques, including
CT, MR, and sonography, accounting for ap-
proximately 60% of renal tumors in the 1990s,
compared with approximately 10% in the early
1970s [3, 4].
Besides identifying these incidental le-
sions, diagnostic imaging plays an increasing
role in this disease, particularly in the con-
text of newer surgical approaches such as
es. MDCT has been a major advance, provid-
ing angiographic and 3D imaging essential
for presurgical planning.
This article focuses on the epidemiology,
pathology, staging, radiologic evaluation,
and therapeutic options of RCC and the im-
plications for radiologic follow-up.
Epidemiology
There were an estimated 51,190 new cases
of, and 12,890 deaths from, renal cancer in
2007 in the United States, accounting for
2.3% of all cancer deaths in the United States
[1]. The incidence has steadily increased
during the past 50 years in the United States
and has occurred in 9.1/100,000 population
in 1997, with a mortality rate of 3.5/100,000
[5–7]. Reported worldwide incidence rates
range from 0.6/100,000 to 14.7/100,000 [8].
Most tumors present in the fifth to seventh
decade of life, with a median age at diagnosis
of 66 years and median age at death of 70
years. The incidence is two to three times
higher in men and is slightly more common
in blacks than in whites [5]. The incidence of
renal tumors at autopsy is approximately 2%
[9]. The tumors are usually solitary but may
be multifocal (6–25%), with bilateral RCC
occurring sometime in the course of life in
4% of patients [10].
Certain genetic conditions are associated
with an increased incidence of RCC, including
von Hippel-Lindau disease, hereditary papillary
renal cancer, and, possibly, tuberous sclerosis
[11]. RCC occurs in von Hippel-Lindau disease
in 35–40% of patients, occurs at a younger age,
and is frequently bilateral (75%) or multifocal

1220 AJR:191, October 2008

 Diagnosis and Staging of Renal Cell Carcinoma

(87%) [12]. RCC is also more common in ac-
quired cystic renal disease. Long-term dialy-
sis carries a three- to sixfold increased risk
compared with the normal population. He-
reditary papillary RCC is an autosomal dom-
inant form of the disease that is associated
with multifocal papillary renal tumors. The
disease has a 5:1 male predominance. Other
suggested risk factors include cigarette
smoking; obesity; diuretic use; exposure to
petroleum products, chlorinated solvents,
cadmium, lead, asbestos, and ionizing radia-
tion; high-protein diets; hypertension; kid-
ney transplantation; and HIV infection [5,
10, 13–15].
Survival Statistics
Despite the increasing incidence of the
disease in recent decades, survival has
steadily improved, with a current overall
5-year survival of approximately 62% [7].
American Journal of Roentgenology 2008.191:1220-1232.
in the absence of metastases exceeding 50%;
in the presence of distant metastases, the
5-year survival rate decreases to 10% (with a
10-year survival rate of < 5%).
The possible factors that have contributed
to improved survival include advances in re-
nal imaging and surgical techniques, stage
migration to smaller and lower-stage disease
as a result of earlier diagnosis in asymptom-
atic individuals, and the introduction of im-
munotherapy for advanced disease. Tumor
size has been found to be an independent
predictor of outcome, with larger tumors
having a poorer survival; for example, 5- and
10-year disease-free survivals after surgery
for T1, T2, T3a, T3b, and T3c tumors are ap-
proximately 95% and 91%, 80% and 70%,
66% and 53%, 52% and 43%, and 43% and
42%, respectively [16].
Regarding the potential contribution from
incidentally detected tumors, the overall
atic cases. Although data are not available,
this may very well increase in the new era in
which tumors are being detected incidentally
at an earlier stage and smaller size. Evidence
suggests, although not conclusively, that
asymp­tomatic tumors are smaller and of
lower grade and earlier stage [3, 7].
Pathology
RCC (hypernephroma or Grawitz’s tumor)
is the most common tumor to affect the adult
kidney, accounting for 80–90% of primary
malignant renal neoplasms in adults.
On gross pathology, tumors most often ap-
pear encapsulated. Tumors may be solid, cys-
tic, or mixed, including or engulfing fat and
calcification [17]. As many as 10% of tumors
have some cystic component [18], and such
tumors may be more aggressive [19].
Histologic subtypes according to the Heidel-
berg classification [20] include clear cell (“con-

Prognosis is influenced by the extent of dis- 5-year survival rate is approximately 85% for ventional”) adenocarcinoma (80%), papillary
ease at diagnosis, with a 5-year survival rate such cases, compared with 53% in symptom- (15%), chromophobe (5%), collecting duct
(1%), and unclassified (4%) [21, 22]. Each of
these subtypes has differing cytogenetic and
immunohistochemical profiles as well as dif-
fering prognoses. Histopathologic grading of
the nuclei of the tumor is made by dividing
them into the four-tier Fuhrman nuclear clas-
sification [23], with grade I being the best-dif-
ferentiated and grade IV the most anaplastic.
Clear cell carcinoma displays large uniform
cells with abundant clear cytoplasm rich in gly-
cogen and lipid (Fig. 1A). Clear cell carcinoma
is typically highly vascular. Papillary tumors are
subdivided into type I tumors (Fig. 1B), which
A B occur sporadically and metastasize somewhat
later, and type II (Fig. 1C), which are more likely
inherited, may be multiple, and often present
with a higher Fuhrman grade and poorer prog-
nosis. Collecting duct tumors, which arise from
the medullary collecting duct, often occur in
younger patients and are associated with a poor
overall prognosis. Renal medullary carcinoma is
a rare subtype, closely related to collecting duct
carcinoma and having a poor prognosis, which
occurs in young patients with sickle cell anemia
or sickle trait. Chromophobe tumors and onco-
cytomas, both of which arise from collecting
C D duct epithelium, may be confused on histologic
Fig. 1—Histopathologic slides of renal cell carcinoma (RCC). (H and E) examination but have differing immunohis-
A, Conventional clear cell RCC. Tumor shows large uniform cells with abundant cytoplasm that is rich in tochemical profiles (Fig. 1D). Chromophobe
glycogen.
B, Papillary RCC type I. Tumor papillae are lined by short cuboidal cells with basophilic cytoplasm. Nuclei are
tumors have the best overall prognosis, and on-
small with few inconspicuous nucleoli. Collection of foamy histiocytes is present in middle of lower half of cocytomas are benign.
image. The tumor can extend directly into the
C, Papillary RCC type II. Tumor shows papillae lined by columnar to pseudostratified cells that have striking perinephric fat, ipsilateral adrenal gland, or
eosinophilic cytoplasm.
D, Chromophobe RCC. Note sheet of tumor cells with focal necrosis (upper left corner). Tumor cells have adjacent musculature, and, less frequently,
abundant pale flocculent cytoplasm, prominent cell membranes, perinuclear halos, and wrinkled nuclei. the liver, spleen, pancreas, and colon. Rarely,

AJR:191, October 2008 1221

 Ng et al.

A B C
American Journal of Roentgenology 2008.191:1220-1232.

D E F
Fig. 2—Schematic diagrams of TNM staging of renal cell carcinoma. (© 2008 The University of Texas M. D. Anderson Cancer Center)
A, Stage T1 tumor < 7 cm.
B, Stage T2 tumor > 7 cm.
C and D, Stage T3a tumors involving perinephric fat (C) and adjacent adrenal gland (D).
E, Stage T3b tumor involving renal vein or inferior vena cava (IVC) inferior to diaphragm.
F, Stage T3c tumor involves IVC superior to diaphragm.

the tumor may invade the renal collecting
system. RCC has a propensity for extending,
as tumor thrombus, into the tributaries of the
renal veins and subsequently to the main re-
nal vein, the IVC, the hepatic veins, and po-
tentially the right atrium. Hematogenous
metastases are more common and occur ear-
lier than lymphatic dissemination, the former
most commonly to the lungs and bone, but
essentially to any organ, including the subcu-
taneous tissues and skeletal muscle.
Staging
Staging systems are designed to reflect the
modes of spread (Fig. 2) and are used to strat-
ify treatment options and to assess prognoses
and survival characteristics. The current ver-
sion of the 2002 TNM staging of the Ameri-
can Joint Committee on Cancer (AJCC) and
the International Union Against Cancer
(UICC) is presented in Tables 1 and 2 [24].
In light of the increasing trend for the dis-
covery of very small tumors as incidental
findings on imaging studies performed for
other purposes, revisions to this 1997 version
have been proposed, including subclassifica-
tion of T1 into T1a < 2.5 cm; T1b, 2.5–4.0
cm; and T1c, 5.0–7.0 cm tumors. The Robson
classification [25] is an alternative staging
system no longer used but still referred to in
some of the older literature.
Prognosis is generally reflected in stag-
ing severity, with lower-stage disease being
associated with longer survival rates. Five-
year survival rates by TNM stage are shown
in Table 3. The prognosis is noticeably ad-
versely affected by spread of the tumor be-
yond the renal fascia and into the retroperi-
toneum (TNM T3a and higher). The natural
history of the disease, however, is often un-
predictable, and there are wide ranges in
survival. There are reports, albeit rare (<
1:600), of stabilization or even spontaneous
remissions in the face of metastatic disease
[10, 26].
Crotty et al. [27] reported that 86% of chro-
mophobe tumors in their series were Robson
stage I at presentation. Beck et al. [28] reported
that chromophobe and papillary histology were
associated with an improved disease-free sur-
vival at 5 years compared with patients with

1222 AJR:191, October 2008

 Diagnosis and Staging of Renal Cell Carcinoma

TABLE 1:  TNM Staging of Renal Cell Carcinoma Twenty-five to 33% of patients have overt
Stage Description metastases at presentation [2, 13, 31]. The
more common sites of metastases as reported
TX Primary tumor cannot be assessed
in stage IV disease (TNM T4 or N1+ M1 dis-
T0 No evidence of primary tumor ease) are the lung (69%), bone (43%), liver
T1 Tumor < 7 cm in greatest dimension, limited to kidney (34%), lymph nodes (22%), adrenal gland
  T1a Tumor < 4 cm in greatest dimension, limited to kidney (19%), brain (7%), and thyroid, skin, and blad-
der (< 1% each) [32]. Rarer sites include skel-
  T1b Tumor > 4 cm but < 7 cm in greatest dimension, limited to kidney
etal muscle, bowel, gallbladder, pancreas, and
T2 Tumor ≥ 7 cm in greatest dimension, limited to kidney orbits [10, 13, 33]. Large tumors tend to be as-
T3 Tumor extends into major veins or invades adrenal gland or perinephric tissues, but not beyond sociated with more advanced dissemination.
Gerota’s fascia
  T3a Tumor invades adrenal gland or perinephric tissues but not beyond Gerota’s fascia Radiologic Evaluation
  T3b Tumor grossly extends into renal vein(s) or vena cava below diaphragm
The goals of radiologic imaging are to
detect and stage the primary tumor. In most
  T3c Tumor grossly extends into vena cava above diaphragm institutions, CT is the main imaging tech-
T4 Tumor invades beyond Gerota’s fascia nique for the evaluation of the intra-
NX Regional lymph nodes cannot be assessed abdominal component of renal tumors. In
some specific instances, such as allergy to
N0 No regional lymph node metastasis
iodinated contrast medium, MRI and sono-
N1 Metastasis in a single regional lymph node graphy can provide complementary infor-
American Journal of Roentgenology 2008.191:1220-1232.

N2 Metastasis in more than one regional lymph node mation. The risks of nephrogenic systemic
MX Distant metastasis cannot be assessed fibrosis (NSF) in patients with significantly
impaired renal function, which is consid-
M0 No distant metastasis
ered to be associated with some gadolini-
M1 Distant metastasis um-based MRI contrast agents, should be
Note—Adapted from current version of American Joint Committee on Cancer (2002) [24]. considered carefully when staging with
MRI is deemed advisable [34].
It is generally considered that a risk-adapt-
clear cell RCC. When controlled for size and that should be included in staging, including ed approach is used for workup of other pos-
stage of tumor, however, chromophobe, but not recognition of RCC tumor variants, sarcomatoid sible sites of metastases. Chest CT should be
papillary, carcinoma offered a significantly im- histology, histopathologic grade, molecular performed if the primary tumor is large or
proved survival. The times from nephrectomy proliferation markers (silver-staining nucleolar locally aggressive because metastases are
to metastasis and from metastasis to death were organizer regions, proliferating cell nuclear more common in these patients [35]. Chest
twice those for patients with chromophobe his- antigen, and Ki-67 antigen), performance sta- radiography without CT should be reserved
tology when compared with those with clear tus, weight loss, hypercalcemia, and erythro- for patients with a low risk of metastatic dis-
cell or papillary subtypes. cyte sedimentation rate [7, 10, 29, 30]. How- ease or for those in long-term follow-up [36,
It has been suggested that there are other ever, current staging does not incorporate 37]. Brain MRI and nuclear medicine bone
potentially important determinants of survival these factors. scanning are generally justified only if there

TABLE 2:  TNM Stage Groupings TABLE 3:  Survival by TNM Stage
Stage T N M Disease Extent TNM Stage 5-Year Survival Rate (%)
Grouping Stage Stage Stage
All organ-confined T1–T2 N0 M0 70–90
I T1 N0 M0
≤ 4 cm T1a N0 M0 90–100
II T2 N0 M0
> 4 but < 7 cm T1b N0 M0 80–90
III T1 N1 M0
≥ 7 cm T2 N0 M0 70–80
T2 N1 M0
Invasion of perinephric fat T3a N0 M0 60–80
T3 N0 M0
Adrenal involvement T3a N0 M0 0–30
T3 N1 M0
Venous involvement T3b–T3c N0 M0 40–65
IV T4 N0 M0
Locally advanced T4 N0 M0 0–20
T4 N1 M0
Lymphatic involvement Any T, N+, M0 0–20
Any T N2 M0
Systemic metastases Any T, any N, M1 0–10
Any T Any N M1
Note—Adapted from current version of American Joint Committee on Cancer (2002) [24].
Note—Adapted from current version of American
Joint Committee on Cancer (2002) [24].

AJR:191, October 2008 1223


A B
American Journal of Roentgenology 2008.191:1220-1232.
D E
are symptoms and signs to suggest disease at
these sites or if the tumor is large and locally
aggressive, although even the latter is debat-
ed [31]. Technetium-99m-methylene diphos-
phonate (MDP) bone scanning, however,
may be limited in detecting the typical osteo­
lytic bone metastases from RCC. The value
of pelvic CT in staging is also limited [38].
CT Evaluation
Suggested protocols for preoperative eval-
uation and follow-up using MDCT are pre-
sented in the text that follows. In addition to
assessing tumor stage, preoperative evalua-
tion focuses on delineating the tumor with
particular attention to the relationship of the
tumor to adjacent structures, including vas-
cular relationships. In comparison, follow-up
evaluation is directed toward surveillance for
residual or recurrent disease. In general,
100–150 mL of iodinated IV contrast medi-
um is used at a flow rate of 2–3 mL/s.
Preoperative Evaluation
For an MDCT protocol, unenhanced im-
ages of the liver and kidneys are obtained
with 5-mm collimation in 5-mm increments.
Unenhanced images of the kidneys allow de-
tection of calcification or fat in the kidney,
1224 AJR:191, October 2008
Ng et al.
enable assessment of contrast enhancement,
and assist in characterizing the lesion. IV
contrast-enhanced images targeted on the
kidneys are obtained in the arterial, late arte-
rial (corticomedullary and portal venous),
nephrographic, and excretory phases at
15–30, 45–60, 80–90, and 180 seconds, re-
spectively, after commencement of the IV
infusion. Imaging of the liver and the re-
maining abdominal structures is performed
in the portal venous phase. Excretory phase
images from the kidneys through the bladder
are generally obtained to complete the evalu-
ation of the entire urinary tract when re-
quested by the referring clinician.
Multiplanar reformatted and 3D volume-
rendered presentations of the renal phase im-
ages are helpful in allowing visualization of
the relationships of structures, particularly for
surgeons [39–41]. Such reformations are best
obtained with the thinnest possible images
and some degree of reconstruction interval
overlap (typically, < 1.5-mm interval and
10–50% overlap) and are transferred to a
workstation for creating multiplanar reformat-
ted images, 3D volume rendering, and maxi-
mum-intensity-projection (MIP) images (Figs.
3A–3D). The late arterial phase provides a
useful angiographic image of arterial and ve-
C
Fig. 3—CT reformations of bilateral renal tumors in
60-year-old woman. Large arrows indicate primary
renal tumor.
A, CT scan shows solid left renal mass (large arrow)
and complex cystic right renal mass (small arrow).
B, Coronal multiplanar reformation (MPR) during
arterial phase shows one left and two right renal
arteries (small arrows).
C, Coronal maximum intensity projection during
arterial phase shows bilateral tumors (large arrows)
and renal arteries (small arrows).
D, Volume-rendered image during arterial phase also
shows renal arteries (small arrows).
E, 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).
nous supply to the kidney but has limited ad-
ditional usefulness for lesion detection and
characterization when a nephrographic phase
is used. The combination of excretory and
nephrographic phases has been shown to im-
prove lesion detection and staging [42, 43].
Several investigators have shown that clear
cell RCC enhances to a greater extent and is
more heterogeneous in appearance than other
histologic subtypes (Figs. 4A and 4B). Kim et
al. [44] showed that an increase in attenuation
of 84 HU in the corticomedullary phase dif-
ferentiates clear cell RCC from non–clear cell
tumors with a sensitivity of 74% and a speci-
ficity of 100%. Herts et al. [45] showed that
papillary tumors were more homogeneous
and had a much lower tumor-to-parenchyma
enhancement ratio than was present in non-
papillary subtypes, particularly with tumors
smaller than 3 cm in diameter (Figs. 4C and
4D). Chromophobe tumors also are less hyper­­
vascular than clear cell tumors and tend to
have a more peripheral pattern of enhancement;
however, their appearance is not sufficiently
characteristic to allow them to be reliably dif-
ferentiated from papillary lesions (Figs. 4E
and 4F). Oncocytomas cannot be reliably dif-
ferentiated from RCC by imaging and thus are
also considered to be surgical lesions. The
 Diagnosis and Staging of Renal Cell Carcinoma
A B
American Journal of Roentgenology 2008.191:1220-1232.
C D
E F
be suggested when an aggressive tumor in a
young patient with sickle cell disease or trait
is encountered.
Follow-Up Evaluation
For an MDCT protocol, unenhanced im-
ages of the liver and kidneys are obtained
with 5-mm collimation in 5-mm increments.
Unenhanced images of the liver assist in the
detection of hypervascular metastases (which
are typical of renal metastases) that might
G otherwise be obscured on contrast-enhanced
images. IV contrast-enhanced images of the
well-known prominent central scar that can abdomen and pelvis are obtained 70–80 sec-
be used to suggest the diagnosis of oncocyto- onds after the beginning of the IV infusion,
ma may also be present in necrotic clear cell acquired at 5-mm slice thickness, and recon-
tumors. Medullary RCC tumors are located structed at 2.5-mm intervals. Late arterial
centrally in the kidney and show variable, phase images can assist in identifying hyper-
typically limited, contrast enhancement (Fig. vascular liver metastases. Delayed excretory
4G). They cannot be reliably distinguished phase images are obtained at approximately
from other RCCs or urothelial tumors but may 180 seconds.
AJR:191, October 2008 1225
Fig. 4—CT appearances of various cell types of renal
cell carcinoma (RCC).
A and B, 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).
C and D, 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).
E and F, 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).
G, Medullary RCC (large arrow) and adjacent
paraaortic adenopathy (small arrows) in 36-year-old
man. CT shows TNM stage T1b N1 tumor.
MRI Evaluation
MRI is generally only used when optimal
CT cannot be performed, as in the case of a
severe allergy to iodinated contrast medium
or pregnancy. MRI has similar reported
overall staging accuracies to those of CT
[46]. Its multiplanar capability, however, is
particularly useful for delineating the supe-
rior extent of tumor in the IVC [2, 14, 17].
We use coronal and axial conventional T1-
weighted (TR/TE, 600/60) and axial dual-echo
fast spin-echo T2-weighted (6,000/first­-echo
TE, 136; second-echo TE, 68) fat-suppressed
images of the abdomen. Images are supple-
mented by dynamic contrast-enhanced 3D fast
spoiled gradient-recalled echo sequences
(FSPGR) to further delineate the primary tumor
and liver lesions and to evaluate any vascular
thrombus identified. In particular, tumor, rather
than bland, thrombus is indicated by the pres-
ence of enhancing vessels in the thrombus.
Multiple dynamic acquisitions can be used to
obtain arterial, nephrogenic, and pyelographic-
like images [47–50]. MDCT with 3D reforma-
tions and MRI have similar overall staging ac-
curacies for RCC [51].
Sonographic Evaluation
Sonography can be useful for assessing
the presence and extent of venous thrombus.
It can also be helpful in distinguishing cysts
from hypovascular solid tumors seen on CT
(e.g., papillary RCC). Sonography can reveal
the septations better because of complex in-
terfaces to the ultrasound beam. Sonography
has reported accuracies for T staging of
77–85% [52, 53] and for detection of venous
thrombus of 87% [54]. However, it has limi-
tations in visualizing the retroperitoneum
and perinephric tissues [54, 55], although
some proponents argue otherwise [53]. Intra-
operative sonography has been effectively

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.
used in patients undergoing nephron-sparing
surgery to identify multifocal lesions and in-
trarenal tumor anatomy [56, 57].
American Journal of Roentgenology 2008.191:1220-1232.
Percutaneous Biopsy
Preoperative percutaneous biopsy of the
renal lesion is generally not undertaken be-
cause the results usually do not affect what
therapy will be recommended except in pa-
tients with multiple tumors or occasionally
in patients with an underlying predisposing
condition. Percutaneous biopsies may be
A metastases is probably re­quired only when
C D
1226 AJR:191, October 2008
Ng et al.
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).
considered in selected cases—for example,
when an abscess or metastatic disease from a
known primary tumor is suspected, espe-
cially from lymphoma or melanoma [10, 17].
Percutaneous biopsy is also generally per-
formed in patients who will undergo ablative
or thermal therapy to determine the underly-
ing histologic subtype of the tumor.
Angiography
Approximately 20% of patients have mul-
tiple renal arteries, and many surgeons find
B
preoperative CT or MR angiograms to be
valuable, particularly when partial nephrec-
tomy or laparoscopic approaches are planned.
Three-dimensional and multiplanar refor-
matted images, as well as angiographic dis-
plays, aid appreciation of the relationships of
the tumor to the collecting system, adjacent
normal parenchyma, and vascular supply
[10, 37, 38, 57].
PET
The efficacy of PET in renal malignancy
remains under investigation. It shows some po-
tential in staging, the detection of unsuspected
metastases, follow-up, and the evaluation of
indeterminate renal masses [7, 58–61].
Recommendations for Preoperative Imaging
Patients must be adequately staged in or-
der to plan appropriate management options.
Abdominal CT and MRI are the mainstay of
staging the primary tumor and of evaluating
the possibility of locoregional nodal or ab-
dominal visceral metastases, such as to the
adrenal glands, liver, pancreas, and contra­
lateral kidney. Delineation of vascular anato-
my and evaluation of venous thrombosis,
best provided by a multiphasic evaluation as
discussed previously, are helpful when sur-
gery is being contemplated. CT or MRI can
be used, depending on local preferences and
patient factors.
Controversies exist as to whether, and how
best, to evaluate for the possibility of intra­
thoracic metastases. A stage-directed strat­egy
is probably reasonable: For small primary
tumors (T1), in which the risk of metastatic
disease is small, simple chest radiography is
probably satisfactory. For stage T2 or higher
primary tumors, chest CT should probably
be performed. Screening for bone or brain
there are suggestive symptoms.
Fig. 7—Venous involvement of renal vein and inferior
vena cava (IVC).
A, 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).
B, 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.
C, 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).
D, “Salt-and-pepper” appearance of vascularized
tumor thrombus (arrows) in expanded IVC on CT scan
in 61-year-old woman.
 Diagnosis and Staging of Renal Cell Carcinoma

A B C
American Journal of Roentgenology 2008.191:1220-1232.

D E F

Fig. 8—Metastatic disease (TNM stage M1). Note

G H
Therapeutic Options and Implications
for Radiologic Follow-Up
Surgical resection is the only effective
means of cure for clinically localized renal
tumors [10, 62]. Classically, this involves total
nephrectomy, but more recently, partial or
“nephron-sparing” nephrectomy has been
shown to be equally effective in selected
groups. The indications for partial nephrecto-
my include a tumor < 4 cm, peripheral loca-
tion, absence of the contralateral kidney, bilat-
eral renal tumors, and renal insufficiency.
Another consideration is whether there is a
risk of future impairment of renal function
from another condition or a risk of bilateral
renal tumors (e.g., patients with von Hippel-
Lindau disease in whom future surgeries may
be required).
Radical Nephrectomy
Total nephrectomies are typically undertak-
en via a retroperitoneal posterolateral approach
[10]. It is “radical” when it classically includes
excision of the perirenal fat, including the ipsi-
lateral adrenal gland, and a lymph node dissec-
tion. The dissection involves the region from the
diaphragmatic crus to the aortic bifurcation of
the ipsilateral—and possibly the contralateral—
aspects of the IVC or the aorta [7]. The sensitiv-
ity, specificity, and accuracy for the detection of
perinephric extension of disease by high-resolu-
tion CT have been reported to be 96%, 93%,
hypervascular nature of most metastases.
A, Pulmonary metastases in 76-year-old man. CT
scan shows typical well-defined “cannonball”
nodules (arrows).
B, Mediastinal and hilar nodal metastases (arrows) in
68-year-old man are seen on CT scan.
C, Conventional radiograph shows typical lytic
appearance of metastases (arrows) in 58-year-old
woman.
D, CT scan shows lytic lesion in left iliac bone and
associated hypervascular soft-tissue metastasis
(arrows) in same patient as in C.
E, Hypervascular liver metastases (arrows) are seen
on CT scan in 72-year-old man. Note that these must
be differentiated from hemangiomas.
F, Metastases to left adrenal gland (arrows) in
76-year-old woman.
G, Metastases to skeletal muscle (arrows) in 64-year-
old man.
H, Metastases to pancreas (arrows) in 76-year-old
man.
and 95%, respectively [63] (Fig. 5). Surgical
management is not directly affected by the pres-
ence of perinephric extension of disease be-
cause a radical nephrectomy includes en bloc
removal of all the contents of Gerota’s fascia.
Ipsilateral adrenalectomy is included in
the classic radical nephrectomy. However,
ipsilateral adrenal metastases occur in only
1–10% of patients. It occurs especially in
large left-sided upper pole tumors, usually

AJR:191, October 2008 1227

 Ng et al.

by direct extension (i.e., T3a tumors) [64].
One of the roles of imaging is to assist in
allowing adrenal-sparing nephrectomies in
order to reduce the risk of future adrenal in-
sufficiency [7].
Surgery, although substantially more chal-
lenging, is not necessarily excluded in the pres-
ence of contiguous organ invasion, which typi-
cally involves the liver, diaphragm, psoas
muscles, pancreas, and bowel (Robson stage
IVA, or TNM T4 disease). Both CT and MRI
may have difficulty in distinguishing abutment
of tumor from invasion of adjacent organs.
Partial (Nephron-Sparing) Nephrectomy
Partial nephrectomy is a relatively new
technique. When evaluating this possibility,
the relationship of the tumor to the rest of the
kidney and, in particular, to the arterial sup-
ply to the tumor and the remainder of the
kidney, is important. Nephron-sparing sur-
American Journal of Roentgenology 2008.191:1220-1232.
[70]—which may be more common in necrotic
tumors or tumors that involve the renal vein.
Conversely, small nodes may contain micro-
metastases—that is, false-negative metastases
(4% in the series by Studer et al.).
It is reported that 3–22.5% of patients who
undergo radical nephrectomy without clini-
cally evident metastases have regional nodal
involvement at surgery [67, 71]. In pathologic
series, the prevalence of metastatic nodes in
cases of occult RCC diagnosed only at autop-
sy is reported at 14% [72].
Accurate determination of nodal staging
requires tissue; some surgeons therefore ad-
vocate routine retroperitoneal nodal dissec-
tion. However, the clinical value of this is
controversial, in particular as to whether it
affects survival, and surgeons vary in their
approach [10, 26, 57, 67, 73].
Venous Involvement
tumors because of the shorter renal vein on
the right [53, 76].
Identification of thrombus in the venous
system, especially the IVC, is particularly im-
portant because it affects surgical manage-
ment, typically necessitating an anterior ab-
dominal approach. Furthermore, if thrombus
extends into the heart, a combined thoracic
and intracardiac approach with cardiac by-
pass may be required.
Current CT techniques have reported sensi-
tivities and specificities for detecting renal vein
thrombus of 85% and 98%, respectively [78].
Color Doppler sonography has reported sensi-
tivities and specificities for detecting thrombus
in the renal veins of 75% and 96%, respective-
ly, with 100% accuracy for detection of throm-
bus in the IVC [54]. MRI has similar reported
sensitivity and specificity for detecting throm-
bus in the renal vein of 86–94% and 75–100%,
respectively, as well as 100% accuracy for de-

gery has been shown to be equally as effica- Extension of tumor into the renal veins has tecting IVC thrombus [79, 80]. MRI, with its
cious as total nephrectomy, with reported been reported to occur in 20–35% of patients, multiplanar capability, is probably the best
local recurrence rates of < 2% [10] and 5-year and into the IVC, in 4–10% [74–76], the latter technique for identifying the superior extent of
survival rates of 87–90%, which are compa- being infrahepatic (50%), intrahepatic (40%), IVC involvement [49, 81].
rable to those from radical nephrectomy [57]. or intraatrial (10%) [77] (Figs. 7A–7C). IVC Fortunately, prognosis is not adversely af-
However, in the case of a solitary kidney, a thrombus is more common from right-sided fected by tumor in the venous system or by its
risk of developing proteinuria, focal segmen-
tal glomerulosclerosis, and progressive renal
failure exists if more than 50% of the renal
mass is removed [57].
Both total and partial nephrectomies can
be undertaken laparoscopically. Some sur-
geons supplement the laparoscopic approach
with direct “hand assistance” in the operative
field. Laparoscopic approaches reduce peri-
operative morbidity and length of the hospital
stay. However, operation times are generally
longer, and morcellation of the sample leads A B
to difficulties in pathologic staging and intro-
duces the risk of tumor seeding [10]. Cryoab-
lation and radiofrequency ablation, which
may be undertaken laparoscopically or percu-
taneously, are promising techniques for treat-
ing small tumors [30, 57, 65].

Nodal Status and Dissection

The presence of nodal metastases is an ad-
verse prognostic factor [66, 67]. Using a cutoff
of 1 cm for short-axis nodal size, sensitivity and
specificity have been reported to be 83% and
88% [68] and overall accuracies have been re-
ported to be 83–89% [68, 69] (Fig. 6). Howev-
er, radiologic assessment of nodal status, in
common with other tumors, has its limitations.
Enlarged (> 1 cm) nodes are not necessarily
metastatic but may be reactive—that is, false-
positive (58% in one series by Studer et al.
C D
Fig. 9—Local recurrence after nephrectomy as seen on CT.
A, Postsurgical appearances in left nephrectomy bed (lower arrow) in 52-year-old man resolved at follow-up.
Note associated surgical vascular clips (upper arrow).
B, Local tumor recurrence is seen in left nephrectomy bed (arrows) in same patient as in A.
C, 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.
D, Follow-up CT scan in same patient as in C shows gas in bowel loops (large and small arrows).

1228 AJR:191, October 2008

 Diagnosis and Staging of Renal Cell Carcinoma

TABLE 4: Stage-Specific Postoperative Imaging Surveillance After Radical

Nephrectomy for Localized Renal Cell Carcinoma
Stage Chest Radiography Abdominal CT
T1 Yearly
T2 Every 3 and 6 months, then every 6 months for 3 years, then annually 2 and 5 years
T3 3 and 6 months, then every 6 months for 3 years, then annually 2 and 5 years
Note—Adapted from Levy et al. [95].

A B
American Journal of Roentgenology 2008.191:1220-1232.

Fig. 11—CT appearances after partial nephrectomy in 55-year-old man.

A, CT scan obtained 6 weeks after left partial nephrectomy shows low-density lesion (arrow) at surgical site
that could be confused with mass lesion.
B, Six months after partial nephrectomy, note resolution of postoperative changes (arrow). Also note previous
right nephrectomy.

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).
level in the IVC, provided the tumor is free-
floating and can be successfully removed
(5-year survival rates of 50–69% in the ab-
sence of metastatic disease). However, prog-
nosis is severely impaired if tumor invades
the wall of the IVC (5-year survival rate,
25%), although this can improve if the in-
volved IVC can be resected completely
(5-year survival rate, 57%) [2, 66, 82]. Un-
fortunately, current imaging techniques have
some limitations in distinguishing bland
thrombus from tumor thrombus and in dis-
tinguishing invasive from noninvasive tumor
with respect to the vessel wall [2]. Intra-
vascular tissue that enhances after IV con-
trast administration or that contains neovas-
cularization (the thread-and-streak sign) is
good evidence of tumor thrombus rather than
bland thrombus (Fig. 7D).
Metastatic Disease and Palliation
In the context of metastatic disease, a nephre-
ctomy may still be indicated for sympto­matic
relief—for example, severe pain or hematuria; in
a small number of cases (≈ 0.3%), regression of
metastases has been reported after resection of
the primary tumor. Cytoreductive nephrectomy
has been shown to offer a survival benefit in se-
lected patients with metastatic disease [83]. Pre-
operative embolization can provide symptomatic
relief and reduce intraoperative bleeding in large
tumors. Also, resection is sometimes performed
to obtain material needed in immunotherapy.
Radiation therapy is sometimes used for pallia-
tion—for example, pain from bone metastases.
Immunotherapy and Targeted Therapies
The mainstay of systemic therapy for meta-
static RCC has historically been immunother-
apy (or cytokine therapy) with interleukin-2
(IL-2) and interferon-α (IFN-α). High-dose
IL-2 has consistently produced a 15–20% re-
sponse rate, 6–8% complete remission rate,
and approximately 5% cure rate [84, 85];
however, it is a fairly toxic regimen. IFN-α
has provided modest survival benefit, has a
more favorable toxicity profile, and is more
easily administered than IL-2. As a result,
IFN-α has been adopted as the control arm in
many clinical trials of novel agents.
Novel therapies for metastatic RCC have tar-
geted the consequences of von Hippel-Lindau
(VHL) gene inactivation and the resulting up-
regulation of hypoxia-inducible factor (HIF)
target genes, notably vascular endothelial growth
factor (VEGF) and platelet-derived growth fac-
tor (PDGF). Four targeted agents are presently
in clinical use for metastatic RCC: sunitinib,
sorafenib, temsirolimus, and bevacizumab.
Sunitinib (Sutent, Pfizer), a multi­­tyrosine kinase
inhibitor (MKI), has shown an objective re-
sponse rate (ORR) of 31% and a median pro-
gression-free survival of 11 months for sunitinib-
treated patients [86, 87]. It is considered the
standard-of-care treatment for patients with ad-
vanced, good- and intermediate-risk, conven-
tional clear cell RCC. Sorafenib (Nexavar, Bayer
HealthCare), another MKI, is considered sec-
ond-line therapy after cytokine failure [88].
Temsirolimus (Torisel, Wyeth), an inhibitor of
mammalian target of rapamycin (mTOR), is
considered the standard of care for patients with
poor-risk metastatic RCC, irrespective of histol-
ogy [89, 90]. Bevacizumab (Avastin, Genen-
tech), a humanized antibody to VEGF, has
shown promise in patients with good- and inter-
mediate-risk metastatic RCC [91] but has not yet
been approved for metastatic RCC by the U.S.
Food and Drug Administration (FDA).
Postoperative Surveillance and
Recurrent Disease
Local recurrence in the nephrectomy bed
occurs in approximately 20–40% of patients,
typically in the first 5 years after nephrectomy
[17, 36]; the risks are highest when the resection
margins are incomplete. Isolated recurrences

AJR:191, October 2008 1229

 Ng et al.

in the nephrectomy bed are uncommon (1.8%)
[92], and resection is typically difficult [10] but
in selected patients may improve survival.
Chae et al. [93] analyzed the patterns of re-
currence in 194 patients with RCC who had
undergone complete resection. Tumor recur-
rence was found in 21% of the patients within a
mean time of 17 months. Tumor recurrence oc-
curred within 2 years in 83% of the patients.
The recurrence rate was highest for those with
an original tumor greater than 5 cm and, as ex-
pected, for those with a higher Fuhrman grade
and higher stage at the time of presentation.
Metastasectomies are of uncertain value
[10, 94] but may be efficacious in certain sub-
groups—for example, those with a solitary
site of disease and a prior disease-free interval
of greater than 1 year [26]. Resection of soli-
tary metastases, typically to the lung, can re-
sult in 5-year survival of 25–60% [10].
The likelihood of developing metastases is
American Journal of Roentgenology 2008.191:1220-1232.
technique is required; for example, unopacified
small-bowel loops, which inevitably occupy
the nephrectomy bed, can mimic local recur-
rence (Fig. 9). Sonography has not been found
to be reliable in assessing the nephrectomy bed.
During the surveillance period, it is recom-
mended that evaluation of potential intratho-
racic disease be undertaken by chest radiogra-
phy, with chest CT, bone scanning (Fig. 10),
and brain MRI reserved for patients with suspi-
cious clinical symptoms, signs, and abnormal
blood chemistries. A suggested stage-specific
postoperative imaging surveillance protocol
after radical nephrectomy for localized RCC is
presented in Table 4, although some argue for
more intensive surveillance [71].
The follow-up strategy after nephron-spar-
ing surgery is similar, except that particular at-
tention should be paid to the remnant kidney,
where local recurrence rates are in the region of
4–6% (Fig. 11). These occur a maximum of
More specialized follow-up may be re-
quired for patients with end-stage renal dis-
ease, acquired cystic disease of the kidney,
or von Hippel-Lindau disease [10]. One of
the features of RCC is that it can have an un-
predictable time course, with recurrence-free
intervals of up to 30 years; prolonged periods
of follow-up may therefore be needed [53].
References
1. Jemal A, Siegel R, Ward E, Murray T, Xu J, Thun
MJ. Cancer statistics, 2007. CA Cancer J Clin
2007; 57:43–66
2. Choyke Pl, Newhouse JH, Bluth EI, et al. ACR ap-
propriateness criteria: renal cell carcinoma stag-
ing, 2002. American College of Radiology Web-
site. www.acr.org. Accessed December 9, 2002
3. Luciani LG, Cestari R, Tallarigo C. Incidental re-
nal cell carcinoma: age and stage characterization
and clinical implications—study of 1092 patients
(1982–1997). Urology 2000; 56:58–62

directly related to tumor stage. In one series after
radical nephrectomy, metastatic disease oc-
curred in 7.1% of patients with stage T1 disease,
26.5% with stage T2, and 39.4% with stage T3
disease, with the chance of developing recurrent
metastases greatest in the first three postopera-
tive years [95]. Sites of metastatic disease include
the lung (Figs. 8A and 8B), bone (Figs. 8C and
8D), liver (Fig. 8E), adrenal gland (Fig. 8F), skel-
etal muscle (Fig. 8G), and pancreas (Fig. 8H).
CT is the most sensitive imaging technique
for follow-up in the abdomen. A meticulous
TABLE 5: Stage-Specific Postoperative Imaging Surveillance After Partial
Nephrectomy For Localized Renal Cell Carcinoma
Stage Chest Radiography
T1
T2 Yearly
T3 Every 6 months for 3 years, then yearly
Note—Adapted from Novick [57].
6–24 months after surgery in patients with
stage T3 disease, and later than 48 months in
stage T2 disease. Recurrences are most likely
the result of undetected microscopic multifocal
RCC in the remnant kidney [57]. In pathologic
series, multifocality in primary tumors < 5 cm
in size is 19% [96]. A suggested stage-specific
postoperative imaging surveillance protocol
after partial nephrectomy for localized RCC is
presented in Table 5. Careful follow-up is also
required for patients who have undergone abla-
tion therapies (Fig. 12).
Abdominal CT
Every 2 years
Every 6 months for 3 years, then yearly
4. Jayson M, Sanders H. Increased incidence of seren-
dipitously discovered renal cell carcinoma. Urology
1998; 51:203–205
5. Chow WH, Devesa SS, Warren JL, Fraumeni JF
Jr. Rising incidence of renal cell cancer in the
United States. JAMA 1999; 281:1628–1631
6. Katner HP, Baynham SA. Increasing incidence of
renal cell cancer. JAMA 1999; 282:2119–2120;
discussion 2121
7. Pantuck AJ, Zisman A, Belldegrun AS. The changing
natural history of renal cell carcinoma. J Urol 2001;
166:1611–1623
8. Parkin DM, Pisani P, Ferlay J. Estimates of the
worldwide incidence of 25 major cancers in 1990.
Int J Cancer 1999; 80:827–841
9. Choyke PL, Amis ES Jr, Bigongiari LR, et al. Re-
nal cell carcinoma staging. American College of
Radiology. ACR appropriateness criteria. Radiol-
ogy 2000; 215[suppl]:721–725
10. Russo P. Renal cell carcinoma: presentation, stag-
ing, and surgical treatment. Semin Oncol 2000;

A B C
Fig. 12—Local recurrence after cryoablation as seen on CT of 61-year-old man.
A, Scan before ablation shows hypervascular tumor (arrow) adjacent to cyst.
B, Scan 2 months after ablation shows low-density lesion with minimal marginal enhancement, typical of postablation changes (arrow).
C, Local recurrence (arrow) is seen 18 months after ablation.

1230 AJR:191, October 2008

 Diagnosis and Staging of Renal Cell Carcinoma
27:160–176
11. Bjornsson J, Short MP, Kwiatkowski DJ, Henske
EP. Tuberous sclerosis-associated renal cell carci-
noma: clinical, pathological, and genetic features.
Am J Pathol 1996; 149:1201–1208
12. Levine E, Weigel JW, Collins DL. Diagnosis and
management of asymptomatic renal cell carcino-
mas in von Hippel-Lindau syndrome. Urology
1983; 21:146–150
13. Figlin RA. Renal cell carcinoma: management of
advanced disease. J Urol 1999; 161:381–386; dis-
cussion 386–387
14. Pretorius ES, Wickstrom ML, Siegelman ES. MR
imaging of renal neoplasms. Magn Reson Imag-
ing Clin N Am 2000; 8:813–836
15. Godley P, Kim SW. Renal cell carcinoma. Curr
Opin Oncol 2002; 14:280–285
16. American Cancer Society. How is kidney cancer
staged? 2007. American Cancer Society Website.
www.cancer.org/docroot/CRI/content/CRI_2_
4_3X_How_is_kidney_cancer_staged_22.
American Journal of Roentgenology 2008.191:1220-1232.
asp?rnav=cri. Accessed October 16, 2007
17. Hilton S. Imaging of renal cell carcinoma. Semin
Oncol 2000; 27:150–159
18. Parienty RA, Pradel J, Parienty I. Cystic renal
cancers: CT characteristics. Radiology 1985;
157:741–744
19. Brinker DA, Amin MB, de Peralta-Venturina M,
Reuter V, Chan DY, Epstein JI. Extensively necrotic
cystic renal cell carcinoma: a clinicopathologic
study with comparison to other cystic and necrotic
renal cancers. Am J Surg Pathol 2000; 24:988–995
20. Kovacs G, Akhtar M, Beckwith BJ, et al. The
Heidelberg classification of renal cell tumours. J
Pathol 1997; 183:131–133
21. Shanks JH. Pathology of renal cell carcinoma: re-
cent developments. Clin Oncol (R Coll Radiol)
1999; 11:263–268
22. Bostwick DG, Eble JN. Diagnosis and classifica-
tion of renal cell carcinoma. Urol Clin North Am
1999; 26:627–635
23. Fuhrman SA, Lasky LC, Limas C. Prognostic sig-
nificance of morphologic parameters in renal cell
carcinoma. Am J Surg Pathol 1982; 6:655–663
24. American Joint Committee on Cancer. AJCC
cancer staging manual. New York, NY: Springer-
Verlag, 2002
25. Robson CJ. Staging of renal cell carcinoma. Prog
Clin Biol Res 1982; 100:439–445
26. Rini BI, Vogelzang NJ. Prognostic factors in renal
carcinoma. Semin Oncol 2000; 27:213–220
27. Crotty TB, Farrow GM, Lieber MM. Chromo-
phobe cell renal carcinoma: clinicopathological
features of 50 cases. J Urol 1995; 154:964–967
28. Beck SD, Patel MI, Snyder ME, et al. Effect of
papillary and chromophobe cell type on disease-
free survival after nephrectomy for renal cell car-
cinoma. Ann Surg Oncol 2004; 11:71–77
AJR:191, October 2008 1231
29. Delahunt B. Histopathologic prognostic indica-
tors for renal cell carcinoma. Semin Diagn Pathol
1998; 15:68–76
30. Tsui KH, Shvarts O, Smith RB, Figlin RA,
deKernion JB, Belldegrun A. Prognostic indicators
for renal cell carcinoma: a multivariate analysis of
643 patients using the revised 1997 TNM staging
criteria. J Urol 2000; 163:1090–1095; quiz 1295
31. Staudenherz A, Steiner B, Puig S, Kainberger F,
Leitha T. Is there a diagnostic role for bone scan-
ning of patients with a high pretest probability for
metastatic renal cell carcinoma? Cancer 1999;
85:153–155
32. Zagoria RJ, Bechtold RE. The role of imaging in
staging renal adenocarcinoma. Semin Ultrasound
CT MR 1997; 18:91–99
33. Ng CS, Loyer EM, Iyer RB, David CL, DuBrow
RA, Charnsangavej C. Metastases to the pancreas
from renal cell carcinoma: findings on three-
phase contrast-enhanced helical CT. AJR 1999;
172:1555–1559
34. Broome DR, Girguis MS, Baron PW, Cottrell AC,
Kjellin I, Kirk GA. Gadodiamide-associated
nephrogenic systemic fibrosis: why radiologists
should be concerned. AJR 2007; 188:586–592
35. Choyke Pl, Amis ES, Bigongiari LR, et al. ACR
appropriateness criteria: renal cell carcinoma stag-
ing, 1998. American College of Radiology Website:
www.acr.org. Accessed December 9, 2002
36. Chin AI, Lam JS, Figlin RA, Belldegrun AS. Sur-
veillance strategies for renal cell carcinoma patients
following nephrectomy. Rev Urol 2006; 8: 1–7
37. Curry NS, Francis IR, Baumgarten DA, et al.
ACR appropriateness criteria: renal cell carcino-
ma staging, 2007. American College of Radiology
Website: www.acr.org. Accessed March 27, 2008
38. Fielding JR, Aliabadi N, Renshaw AA, Silverman
SG. Staging of 119 patients with renal cell carci-
noma: the yield and cost-effectiveness of pelvic
CT. AJR 1999; 172:23–25
39. Sheth S, Scatarige JC, Horton KM, Corl FM,
Fishman EK. Current concepts in the diagnosis
and management of renal cell carcinoma: role
of multidetector CT and three-dimensional CT.
RadioGraphics 2001; 21[spec no]:S237–S254
40. Urban BA, Ratner LE, Fishman EK. Three-di-
mensional volume-rendered CT angiography of
the renal arteries and veins: normal anatomy,
variants, and clinical applications. RadioGraph-
ics 2001; 21:373–386; questionnaire 549–555
41. Wunderlich H, Reichelt O, Schubert R, Zermann
DH, Schubert J. Preoperative simulation of partial
nephrectomy with three-dimensional computed
tomography. BJU Int 2000; 86:777–781
42. Kopka L, Fischer U, Zoeller G, Schmidt C, Ring-
ert RH, Grabbe E. Dual-phase helical CT of the
kidney: value of the corticomedullary and neph-
rographic phase for evaluation of renal lesions and
preoperative staging of renal cell carcinoma. AJR
1997; 169:1573–1578
43. Yuh BI, Cohan RH. Different phases of renal en-
hancement: role in detecting and characterizing renal
masses during helical CT. AJR 1999; 173: 747–755
44. Kim JK, Kim TK, Ahn HJ, Kim CS, Kim KR, Cho
KS. Differentiation of subtypes of renal cell carcino-
ma on helical CT scans. AJR 2002; 178: 1499–1506
45. Herts BR, Coll DM, Novick AC, et al. Enhance-
ment characteristics of papillary renal neoplasms
revealed on triphasic helical CT of the kidneys.
AJR 2002; 178:367–372
46. Beer AJ, Dobritz M, Zantl N, Weirich G, Stollfuss
J, Rummeny EJ. Comparison of 16-MDCT and
MRI for characterization of kidney lesions. AJR
2006; 186:1639–1650
47. Choyke PL. Detection and staging of renal cancer.
Magn Reson Imaging Clin N Am 1997; 5:29–47
48. Zhang J, Israel GM, Krinsky GA, Lee VS. Masses
and pseudomasses of the kidney: imaging spectrum
on MR. J Comput Assist Tomogr 2004; 28:588–595
49. Hallscheidt PJ, Fink C, Haferkamp A, et al. Preop-
erative staging of renal cell carcinoma with inferior
vena cava thrombus using multidetector CT and
MRI: prospective study with histopathological cor-
relation. J Comput Assist Tomogr 2005; 29:64–68
50. Tuite DJ, Geoghegan T, McCauley G, Govender P,
Browne RJ, Torreggiani WC. Three-dimensional
gadolinium-enhanced magnetic resonance breath-
hold FLASH imaging in the diagnosis and staging of
renal cell carcinoma. Clin Radiol 2006; 61: 23–30
51. Hallscheidt PJ, Bock M, Riedasch G, et al. Diag-
nostic accuracy of staging renal cell carcinomas
using multidetector-row computed tomography
and magnetic resonance imaging: a prospective
study with histopathologic correlation. J Comput
Assist Tomogr 2004; 28:333–339
52. Frohmuller HG, Grups JW, Heller V. Comparative
value of ultrasonography, computerized tomography,
angiography and excretory urography in the staging
of renal cell carcinoma. J Urol 1987; 138:482–484
53. Bos SD, Mensink HJ. Can duplex Doppler ultra-
sound replace computerized tomography in stag-
ing patients with renal cell carcinoma? Scand J
Urol Nephrol 1998; 32:87–91
54. Habboub HK, Abu-Yousef MM, Williams RD, See
WA, Schweiger GD. Accuracy of color Doppler
sonography in assessing venous thrombus extension
in renal cell carcinoma. AJR 1997; 168: 267–271
55. Fritzsche PJ, Millar C. Multimodality approach to
staging renal cell carcinoma. Urol Radiol 1992;
14:3–7
56. Campbell SC, Fichtner J, Novick AC, et al. Intra-
operative evaluation of renal cell carcinoma: a pro-
spective study of the role of ultrasonography and
histopathological frozen sections. J Urol 1996;
155:1191–1195
57. Novick AC. Advances in the management of local-

ized renal cell cancer. Can J Urol 2000; 7:
960–966
58. Montravers F, Grahek D, Kerrou K, et al. Evalua-
tion of FDG uptake by renal malignancies (primary
tumor or metastases) using a coincidence detection
gamma camera. J Nucl Med 2000; 41:78–84
59. Ramdave S, Thomas GW, Berlangieri SU, et al. Clin-
ical role of F-18 fluorodeoxyglucose positron emis-
sion tomography for detection and management of
renal cell carcinoma. J Urol 2001; 166:825–830
60. Shvarts O, Han KR, Seltzer M, Pantuck AJ, Bell-
degrun AS. Positron emission tomography in uro-
logic oncology. Cancer Control 2002; 9:335–342
61. Majhail NS, Urbain JL, Albani JM, et al. F-18 fluo-
rodeoxyglucose positron emission tomography in
the evaluation of distant metastases from renal cell
carcinoma. J Clin Oncol 2003; 21:3995– 4000
62. Marshall FF, Stewart AK, Menck HR. The Na-
tional Cancer Data Base: report on kidney can-
cers. The American College of Surgeons Com-
mission on Cancer and the American Cancer
American Journal of Roentgenology 2008.191:1220-1232.
Society. Cancer 1997; 80:2167–2174
63. Catalano C, Fraioli F, Laghi A, et al. High-resolu-
tion multidetector CT in the preoperative evalua-
tion of patients with renal cell carcinoma. AJR
2003; 180:1271–1277
64. Sandock DS, Seftel AD, Resnick MI. Adrenal me-
tastases from renal cell carcinoma: role of ipsilat-
eral adrenalectomy and definition of stage. Urol-
ogy 1997; 49:28–31
65. Hafron J, Kaouk JH. Ablative techniques for the
management of kidney cancer. Nat Clin Pract
Urol 2007; 4:261–269
66. Giberti C, Oneto F, Martorana G, Rovida S, Car-
mignani G. Radical nephrectomy for renal cell car-
cinoma: long-term results and prognostic factors on
a series of 328 cases. Eur Urol 1997; 31: 40–48
67. Blom JH, van Poppel H, Marechal JM, et al.;
EORTC Genitourinary Group. Radical nephrec-
tomy with and without lymph node dissection:
preliminary results of the EORTC randomized
phase III protocol 30881. Eur Urol 1999;
36:570–575
68. Johnson CD, Dunnick NR, Cohan RH, Illescas
FF. Renal adenocarcinoma: CT staging of 100 tu-
mors. AJR 1987; 148:59–63
69. Fein AB, Lee JK, Balfe DM, et al. Diagnosis and
staging of renal cell carcinoma: a comparison of
MR imaging and CT. AJR 1987; 148:749–753
70. Studer UE, Scherz S, Scheidegger J, et al. Enlarge-
ment of regional lymph nodes in renal cell carci-
noma is often not due to metastases. J Urol 1990;
144:243–245
F O R YO U R I N F O R M AT I O N
This article is available for CME credit. See www.arrs.org for more information.
1232 AJR:191, October 2008
Ng et al.
71. Saidi JA, Newhouse JH, Sawczuk IS. Radiologic
follow-up of patients with T1-3a,b,c or T4N+M0
renal cell carcinoma after radical nephrectomy.
Urology 1998; 52:1000–1003
72. Johnsen JA, Hellsten S. Lymphatogenous spread
of renal cell carcinoma: an autopsy study. J Urol
1997; 157:450–453
73. Schafhauser W, Ebert A, Brod J, Petsch S, Schrott
KM. Lymph node involvement in renal cell carci-
noma and survival chance by systematic lymph-
adenectomy. Anticancer Res 1999; 19:1573–1578
74. Kearney GP, Waters WB, Klein LA, Richie JP,
Gittes RF. Results of inferior vena cava resection for
renal cell carcinoma. J Urol 1981; 125:769– 773
75. Davits RJ, Blom JH, Schroder FH. Surgical man-
agement of renal carcinoma with extensive in-
volvement of the vena cava and right atrium. Br J
Urol 1992; 70:591–593
76. Kallman DA, King BF, Hattery RR, et al. Renal
vein and inferior vena cava tumor thrombus in re-
nal cell carcinoma: CT, US, MRI and venacavog-
raphy. J Comput Assist Tomogr 1992; 16:240–247
77. Oto A, Herts BR, Remer EM, Novick AC. Inferior
vena cava tumor thrombus in renal cell carcino-
ma: staging by MR imaging and impact on surgi-
cal treatment. AJR 1998; 171:1619–1624
78. Welch TJ, LeRoy AJ. Helical and electron beam
CT scanning in the evaluation of renal vein in-
volvement in patients with renal cell carcinoma. J
Comput Assist Tomogr 1997; 21:467–471
79. Hricak H, Thoeni RF, Carroll PR, Demas BE, Ma-
rotti M, Tanagho EA. Detection and staging of re-
nal neoplasms: a reassessment of MR imaging.
Radiology 1988; 166:643–649
80. Roubidoux MA, Dunnick NR, Sostman HD, Led-
er RA. Renal carcinoma: detection of venous ex-
tension with gradient-echo MR imaging. Radiol-
ogy 1992; 182:269–272
81. Goldfarb DA, Novick AC, Lorig R, et al. Magnetic
resonance imaging for assessment of vena caval tu-
mor thrombi: a comparative study with venacavog-
raphy and computerized tomography scanning. J
Urol 1990; 144:1100–1103; discussion 1103–1104
82. Hatcher PA, Anderson EE, Paulson DF, Carson CC,
Robertson JE. Surgical management and prognosis
of renal cell carcinoma invading the vena cava.
J Urol 1991;145:20–23; discussion 23–24
83. Kassouf W, Sanchez-Ortiz R, Tamboli P, et al.
Cytoreductive nephrectomy for T4NxM1 renal
cell carcinoma: the M. D. Anderson Cancer Cen-
ter experience. Urology 2007; 69:835–838
84. Yang JC, Sherry RM, Steinberg SM, et al. Ran-
domized study of high-dose and low-dose inter-
leukin-2 in patients with metastatic renal cancer. J
Clin Oncol 2003; 21:3127–3132
85. McDermott DF, Regan MM, Clark JI, et al. Ran-
domized phase III trial of high-dose interleukin-2
versus subcutaneous interleukin-2 and interferon
in patients with metastatic renal cell carcinoma. J
Clin Oncol 2005; 23:133–141
86. Motzer RJ, Hutson TE, Tomczak P, et al. Suni-
tinib versus interferon-alfa in metastatic renal-
cell carcinoma. N Engl J Med 2007; 356:115–124
87. Motzer RJ, Figlin RA, Hutson TE, et al. Sunitinib
versus interferon-alfa (IFN-α) as first-line treatment
of metastatic renal cell carcinoma (mRCC): updated
results and analysis of prognostic factors. J Clin On-
col 2007; 25[meeting abstracts suppl]:5024
88. Escudier B, Eisen T, Stadler WM, et al. Sorafenib
in advanced clear-cell renal-cell carcinoma. N
Engl J Med 2007; 356:125–134
89. Hudes G, Carducci M, Tomczak P, et al. Temsiroli-
mus, interferon-alfa, or both for advanced renal-cell
carcinoma. N Engl J Med 2007; 356:2271– 2281
90. Dutcher JP, Szczylik C, Tannir N, et al. Correla-
tion of survival with tumor histology, age, and
prognostic risk group for previously untreated pa-
tients with advanced renal cell carcinoma (adv
RCC) receiving temsirolimus (TEMSR) or inter-
feron-alpha (IFN). J Clin Oncol 2007; 25[meet-
ing abstracts suppl]:5033
91. Escudier B, Koralewski P, Pluzanska A, et al. A ran-
domized, controlled, double-blind phase III study
(AVOREN) of bevacizumab/interferon-{alpha}2a
vs placebo/interferon-{alpha}2a as first-line therapy
in metastatic renal cell carcinoma. J Clin Oncol
2007; 25[meeting abstracts suppl]:3
92. Itano NB, Blute ML, Spotts B, Zincke H. Outcome
of isolated renal cell carcinoma fossa recurrence
after nephrectomy. J Urol 2000; 164:322– 325
93. Chae EJ, Kim JK, Kim SH, Bae SJ, Cho KS. Re-
nal cell carcinoma: analysis of postoperative re-
currence patterns. Radiology 2005; 234:189–196
94. Sella A, Swanson DA, Ro JY, et al. Surgery fol-
lowing response to interferon-alpha-based therapy
for residual renal cell carcinoma. J Urol 1993;
149:19–21; discussion 21–22
95. Levy DA, Slaton JW, Swanson DA, Dinney CP.
Stage-specific guidelines for surveillance after
radical nephrectomy for local renal cell carcino-
ma. J Urol 1998; 159:1163–1167
96. Baltaci S, Orhan D, Soyupek S, Beduk Y, Tulunay
O, Gogus O. Influence of tumor stage, size, grade,
vascular involvement, histological cell type and
histological pattern on multifocality of renal cell
carcinoma. J Urol 2000; 164:36–39
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American Journal of Roentgenology 2008.191:1220-1232.

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Antonio Rotondo, Cristina Rossi. 2014. Radiofrequency thermal ablation of renal tumors. La radiologia medica 119:7, 499-511.
[Crossref]
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Lorenzo Cohen. 2014. Randomized Controlled Trial of Expressive Writing for Patients With Renal Cell Carcinoma. Journal
of Clinical Oncology 32:7, 663-670. [Crossref]
56. Jonas Schiffmann, Marco Bianchi, Maxine Sun, Andreas Becker. 2014. Trends in Surgical Management of T1 Renal Cell
Carcinoma. Current Urology Reports 15:2. . [Crossref]
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Lalwani, Vikas Kundra. 2014. Staging, surveillance, and evaluation of response to therapy in renal cell carcinoma: role of MDCT.
Abdominal Imaging 39:1, 66-85. [Crossref]
 58. Dilibaier Wuxiuer, Yun Zhu, Takunori Ogaeri, Keiji Mizuki, Yuki Kashiwa, Kentaro Nishi, Shin-ichiro Isobe, Tei-ichiro Aoyagi,
Ryoiti Kiyama. 2014. Development of Pathological Diagnostics of Human Kidney Cancer by Multiple Staining Using New
Fluorescent Fluolid Dyes. BioMed Research International 2014, 1-6. [Crossref]
59. F. Bazan, M. Busto. 2014. Radiología del carcinoma renal. Radiología 56:1, 61-75. [Crossref]
60. A. Ozcan, B. Krishnan, L. Truong. Renal Tumors 2869-2899. [Crossref]
61. C. Roy, P. Barthélémy, E. Rust. Aspect post-thérapeutique du cancer du rein 167-179. [Crossref]
62. Emilio Quaia. Imaging of the Postoperative Kidney 807-824. [Crossref]
63. Lejla Aganovic, Richard H. Cohan. Renal Tumors 139-145. [Crossref]
64. Blanca Paño Brufau, Carmen Sebastià Cerqueda, Laura Buñesch Villalba, Rafael Salvador Izquierdo, Begoña Mellado González,
Carlos Nicolau Molina. 2013. Metastatic Renal Cell Carcinoma: Radiologic Findings and Assessment of Response to Targeted
Antiangiogenic Therapy by Using Multidetector CT. RadioGraphics 33:6, 1691-1716. [Crossref]
65. Robert Radford, Helena Frain, Michael Ryan, Craig Slattery, Tara McMorrow. 2013. Mechanisms of Chemical Carcinogenesis
in the Kidneys. International Journal of Molecular Sciences 14:10, 19416-19433. [Crossref]
66. Saied Froghi, Kamran Ahmed, Mohammad S. Khan, Prokar Dasgupta, Ben Challacombe. 2013. Evaluation of robotic and
laparoscopic partial nephrectomy for small renal tumours (T1a). BJU International 112:4, E322-E333. [Crossref]
67. W Y Kang, D J Sung, B J Park, M J Kim, N Y Han, S B Cho, C H Kang, S H Kang. 2013. Perihilar branching patterns
of renal artery and extrarenal length of arterial branches and tumour-feeding arteries on multidetector CT angiography. The
British Journal of Radiology 86:1023, 20120387. [Crossref]
American Journal of Roentgenology 2008.191:1220-1232.

68. Robert A. Lefkowitz, Jingbo Zhang. Renal Parenchymal Tumor Imaging 1-43. [Crossref]
69. Jalil Afnan, Christoph Wald. Imaging of Renal Cancer 71-91. [Crossref]
70. Marie-France Bellin, David Eiss, Olivier Hélénon, Peter Hallscheidt. Kidney and Renal Pelvis: Tumors 1745-1778. [Crossref]
71. Ezzeldin M. Ibrahim, Ghieth A. Kazkaz, Khaled M. Abouelkhair, Ali M. Bayer, Osama A. Elmasri. 2012. Sunitinib adverse
events in metastatic renal cell carcinoma: a meta-analysis. International Journal of Clinical Oncology . [Crossref]
72. Lucas Teixeira e Aguiar Batista, Leandro Luongo Matos, Leopoldo Ruiz Machado, Eloah Rabello Suarez, Thérèse Rachell
Theodoro, João Roberto Maciel Martins, Helena Bonciani Nader, Antonio Carlos Lima Pompeo, Maria Aparecida da Silva
Pinhal. 2012. Heparanase expression and glycosaminoglycans profile in renal cell carcinoma. International Journal of Urology
19:11, 1036-1040. [Crossref]
73. Yinghua Liu, Turun Song, Zixing Huang, Suchuan Zhang, Yuan Li. 2012. The accuracy of multidetector Computed
Tomography for preoperative staging of renal cell carcinoma. International braz j urol 38:5, 627-636. [Crossref]
74. Gunes Mustafa, Gecit Ilhan, Pirincci Necip, Taken Kerem, Ceylan Kadir. 2012. Nature of Lesions Undergoing Radical
Nephrectomy for Renal Cancer. Asian Pacific Journal of Cancer Prevention 13:9, 4431-4433. [Crossref]
75. Xun Xu, Yong Hou, Xuyang Yin, Li Bao, Aifa Tang, Luting Song, Fuqiang Li, Shirley Tsang, Kui Wu, Hanjie Wu, Weiming
He, Liang Zeng, Manjie Xing, Renhua Wu, Hui Jiang, Xiao Liu, Dandan Cao, Guangwu Guo, Xueda Hu, Yaoting Gui, Zesong
Li, Wenyue Xie, Xiaojuan Sun, Min Shi, Zhiming Cai, Bin Wang, Meiming Zhong, Jingxiang Li, Zuhong Lu, Ning Gu,
Xiuqing Zhang, Laurie Goodman, Lars Bolund, Jian Wang, Huanming Yang, Karsten Kristiansen, Michael Dean, Yingrui Li,
Jun Wang. 2012. Single-Cell Exome Sequencing Reveals Single-Nucleotide Mutation Characteristics of a Kidney Tumor. Cell
148:5, 886-895. [Crossref]
76. Chao Xie, Edward M. Schwarz, Erik R. Sampson, Robinder S. Dhillon, Dan Li, Regis J. O'Keefe, Wakenda Tyler. 2012. Unique
angiogenic and vasculogenic properties of renal cell carcinoma in a xenograft model of bone metastasis are associated with high
levels of vegf-a and decreased ang-1 expression. Journal of Orthopaedic Research 30:2, 325-333. [Crossref]
77. Gail S. Smith, Carolyn K. Donaldson, Richard M. Gore. Radiologic Diagnosis of Renal Masses 1297-1326. [Crossref]
78. Steven C. Campbell, Brian R. Lane. Malignant Renal Tumors 1413-1474.e33. [Crossref]
79. Weiqi Tan, Michelle A.T. Hildebrandt, Xia Pu, Maosheng Huang, Jie Lin, Surena F. Matin, Pheroze Tamboli, Christopher
G. Wood, Xifeng Wu. 2011. Role of Inflammatory Related Gene Expression in Clear Cell Renal Cell Carcinoma Development
and Clinical Outcomes. The Journal of Urology 186:5, 2071-2077. [Crossref]
80. Y. Jain, S. Liew, M.B. Taylor, S.C. Bonington. 2011. Is dual-phase abdominal CT necessary for the optimal detection of
metastases from renal cell carcinoma?. Clinical Radiology 66:11, 1055-1059. [Crossref]
81. Thomas A. Gardner, Temel Tirkes, Matthew Mellon, Michael O. Koch. 2011. Imaging Techniques for the Patient With Renal
Cell Carcinoma. Seminars in Nephrology 31:3, 245-253. [Crossref]
 82. Jurgen J. Fütterer, Stijn T. W. P. J. Heijmijnk. Imaging in Diagnosis and Staging of Urologic Cancers: Magnetic Resonance
Imaging 118-140. [Crossref]
83. Syed M. Nazim, M. Hammad Ather, Kamran Hafeez, Basit Salam. 2011. Accuracy of multidetector CT scans in staging of
renal carcinoma. International Journal of Surgery 9:1, 86-90. [Crossref]
84. Aimin Zhang, Yi Liu, Yizheng Shen, Youhe Xu, Xiangtie Li. 2010. Osteopontin silencing by small interfering RNA induces
apoptosis and suppresses invasion in human renal carcinoma Caki-1 cells. Medical Oncology 27:4, 1179-1184. [Crossref]
85. James E. Lapinski, Longwen Chen, Ming Zhou. 2010. Distinguishing Clear Cell Renal Cell Carcinoma, Retroperitoneal
Paraganglioma, and Adrenal Cortical Lesions on Limited Biopsy Material. Applied Immunohistochemistry & Molecular
Morphology 18:5, 414-421. [Crossref]
86. Mohamed Nageeb Allam, Hazim Ibrahim Tantawey, Mohamed Mustafa Saad, Abdellatif Mohamed Zayed. 2010. Preoperative
staging of renal cell carcinoma using triphasic helical computed tomography. The Egyptian Journal of Radiology and Nuclear
Medicine 41:3, 421-428. [Crossref]
87. Michael J. Leveridge, Peter J. Bostrom, George Koulouris, Antonio Finelli, Nathan Lawrentschuk. 2010. Imaging renal cell
carcinoma with ultrasonography, CT and MRI. Nature Reviews Urology 7:6, 311-325. [Crossref]
88. B Paudyal, P Paudyal, Y Tsushima, N Oriuchi, M Amanuma, M Miyazaki, A Taketomi-Takahashi, Y Nakazato, K Endo.
2010. The role of the ADC value in the characterisation of renal carcinoma by diffusion-weighted MRI. The British Journal
of Radiology 83:988, 336-343. [Crossref]
89. U. Kramer, G. Gakis, C.D. Claussen. 2010. Bildgebende Diagnostik des Nierenzellkarzinoms. Der Onkologe 16:2, 121-130.
[Crossref]
American Journal of Roentgenology 2008.191:1220-1232.

90. T. Charles, V. Lindner, A. Matau, C. Roy, H. Lang. 2010. Cancer du rein. EMC - Urologie 3:4, 1-30. [Crossref]
91. Patrick Kenney, Justin Gould, Sheaumei Tsai, David Canes. Laparoscopic Partial Nephrectomy 187-196. [Crossref]
92. Richard H. Cohan, Ronald J. Zagoria. Renal Tumors 99-103. [Crossref]
93. Emilio Quaia. Imaging of the Postoperative Kidney 811-829. [Crossref]
94. Fred H Menko, Maurice AM van Steensel, Sophie Giraud, Lennart Friis-Hansen, Stéphane Richard, Silvana Ungari,
Magnus Nordenskjöld, Thomas vO Hansen, John Solly, Eamonn R Maher. 2009. Birt-Hogg-Dubé syndrome: diagnosis and
management. The Lancet Oncology 10:12, 1199-1206. [Crossref]
95. Daria E. Setlik, Kevin M. McCluskey, Jeffrey A. McDavit. 2009. Renal Cell Carcinoma Manifesting as a Solitary Bone
Metastasis. RadioGraphics 29:7, 2184-2189. [Crossref]
96. Maryellen R.M. Sun, Ivan Pedrosa. 2009. Magnetic Resonance Imaging of Renal Masses. Seminars in Ultrasound, CT and
MRI 30:4, 326-351. [Crossref]
97. Börje Ljungberg. 2009. Re: Radical Nephrectomy with and without Lymph-Node Dissection: Final Results of European
Organization for Research and Treatment of Cancer (EORTC) Randomized Phase 3 Trial 30881. European Urology 55:6,
1486-1487. [Crossref]
98. Raghunandan Vikram, Chaan S. Ng, Pheroze Tamboli, Nizar M. Tannir, Eric Jonasch, Surena F. Matin, Christopher G.
Wood, Carl M. Sandler. 2009. Papillary Renal Cell Carcinoma: Radiologic-Pathologic Correlation and Spectrum of Disease.
RadioGraphics 29:3, 741-754. [Crossref]