Diagnostic Imaging Pathways - Renal Cell Cancer (Staging)
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This pathway provides guidance on the staging of adult patients with renal carcinoma confirmed by biopsy or previous imaging.
Date reviewed: January 2012
Date of next review: 2017/2018
Published: November 2012
Quick User Guide
Move the mouse cursor over the PINK text boxes inside the flow chart to bring up a pop up box with salient points.
Clicking on the PINK text box will bring up the full text.
The relative radiation level (RRL) of each imaging investigation is displayed in the pop up box.
| SYMBOL | RRL | EFFECTIVE DOSE RANGE |
 | None | 0 |
 | Minimal | < 1 millisieverts |
 | Low | 1-5 mSv |
 | Medium | 5-10 mSv |
 | High | >10 mSv |
Images
Image GalleryNote: These images open in a new page | ||
|---|---|---|
| 1 |  |
Renal Cell Carcinoma Image 1 (Computed Tomography): Large right kidney mass with central necrosis consistent with renal cell carcinoma. There is tumour extension into the right renal vein (arrow).
|
| 2a |  |
Renal Cell Carcinoma
Image 2a: Nephrectomy showing a circumscribed and encapsulated renal cell carcinoma arising from the lower pole of the kidney. The cut surface shows a heterogenous appearance typical of malignancy with patchy areas of necrosis (blue arrow) and haemorrhage (red arrow). |
| 2b |  |
Image 2b (H&E, x10): Histological section of a conventional clear cell renal cell carcinoma showing sheets and nests of malignant cells with intervening thin-walled vessels. The cells demonstrate irregular and hyperchromatic nuclei surrounded by abundant clear cytoplasm (clear cells). |
Teaching Points
Teaching Points
- Staging is usually by CT of the abdomen and chest radiograph
- Other modalities used include chest CT if there is a suspicion of metastasis on chest radiography, nuclear medicine bone scan if the patient has bone pain and MRI or Doppler US if there is equivocal IVC invasion on CT
chest_ct
Chest Computed Tomography (CT)
- Indications 14
- When the chest radiograph is suspicious or positive or
- In large and locally aggressive tumours to help confirm or exclude metastases and defining the extent of disease
doppler
Doppler Ultrasound
- If MRI is unavailable, Dopper US is useful for assessment of tumour extension into the renal veins, the inferior vena cava, and the right side of the heart (sensitivity approaching 100% for delineating tumour thrombus in the intrahepatic or suprahepatic inferior vena cava) 6,7,8,9
- Advantages 1
- Non-invasive
- No exposure to ionising radiation
- Does not require contrast material
- Relatively inexpensive and widely available
- Limitations
- Inferior to CT and MRI for overall staging of renal adenocarcinoma (low sensitivity for detection of tumour thrombus in the infrahepatic inferior vena cava or distal renal vein) 7
- Image distortion secondary to bowel gas and fat
mri
Magnetic Resonance Imaging (MRI)
- Most accurate imaging modality for assessing venous thrombus (83-100% sensitivity) 5,6,7,10,11,12,13
- Indicated when there is equivocal renal vein or inferior vena caval involvement on CT 5,10
- Advantages 1
- Multiplanar imaging
- Superior soft tissue contrast
- Does not require intravascular contrast material
- No exposure to ionising radiation
- Disadvantages - limited availability and high expense
staging
Staging of Renal Cell Carcinoma
- The goal of imaging in patients with renal cell carcinoma is to separate candidates for surgical cure from those with advanced disease 1
- For surgical candidates, imaging allows delineation of the extent of disease for treatment planning 1
- Renal cell carcinoma staging system 1
| Robson Stage |
Disease Extent |
TNM Stage |
|---|---|---|
I |
Tumour confined to kidney (<2.5cm) |
T1 |
Tumour confined to kidney (>2.5cm) |
T2 |
|
II |
Tumour spread to perinephric fat or adrenal |
T3a |
IIIA |
Tumour spread to renal vein |
T3b |
Tumour spread to inferior vena cava |
T3c |
|
IIIB |
Tumour spread to local lymph nodes (LN) |
N1-3 M0 |
IIIC |
Tumour spread to local vessels and LNs |
T3b N1-3 |
IVA |
Tumour spread to adjacent organs (except ipsilateral adrenal) |
T4a |
IVB |
Distant metastases |
M1 N4 |
References
References
References are graded from Level I to V according to the Oxford Centre for Evidence-Based Medicine, Levels of Evidence. Download the document
- Zagoria RJ, Bechtold RE. The role of imaging in staging renal adenocarcinoma. Semin Ultrasound CT MR. 1997;18(2):91-9. (Review article)
- Benson MA, Haaga JR, Resnick MI. Staging renal carcinoma: what is sufficient? Arch Surg. 1989;124(1):71-3. (Level II/III evidence)
- Dinney CPN, Lannon SG, Awad SA, et al. Analysis of imaging modalities, staging systems, and prognostic indicators for renal cell carcinoma. Urology. 1992;39(2):122-9. (Level II evidence). View the reference
- Johnson CD, Dunnick NR, Cohan RH, et al. Renal adenocarcinoma: CT staging of 100 tumours. AJR Am J Roentgenol. 1987;148(1):59-63. (Level III evidence)
- Fein AB, Lee JKT, Balfe DM. Diagnosis and staging of renal carcinoma: a comparison of MR imaging and CT. AJR Am J Roentgenol. 1987;148(4):749-53. (Level II/III evidence)
- Habboub HK, Abu-Yousef MM, Williams RD, et al. Accuracy of color Doppler sonography in assessing venous thrombus extension in renal cell carcinoma. AJR Am J Roentgenol. 1997;168:267-71. (Level III evidence)
- Kallman DA, King BF, Hattery RR, et al. Renal vein and inferior vena cava tumour thrombus in renal cell carcinoma: CT, US, MRI, and venacavography. J Comput Assist Tomogr 1992;16:240-7. (Level II evidence). View the reference
- Didier D, Racle A, Etievent JP, et al. Tumour thrombus of the inferior vena cava secondary to malignant abdominal neoplasms: US and CT evaluation. Radiology. 1987;162:83-9. (Level III/IV evidence)
- Schwerk WB, Schwerk WN, Rodeck G. Venous renal tumour extension: a prospective US evaluation. Radiology. 1985;156:491-5. (Level II evidence). View the reference
- Hricak H, Thoeni RF, Carroll PR, et al. Detection and staging of renal neoplasms: a reassessment of MR imaging. Radiology. 1988;166;643-9. (Level III evidence)
- Goldfarb DA, Novick AC, Lorig R, et al. Magnetic resonance imaging for assessment of vena caval tumor thrombi: a comparative study with venacavography and computerized tomography scanning. J Urol. 1990;144:1100-4. (Level III evidence)
- Semelka RC, Shoenut JP, Magro CM, et al. Renal cancer staging: comparison of contrast enhanced CT and gadolinium enhanced fat-suppressed spin-echo and gradient echo MR imaging. J Magn Reson Imaging. 1993;3(4):597-602. (Level II evidence)
- Horan JJ, Robertson VN, Choyke PL, et al. The detection of renal carcinoma extension into the renal vein and the inferior vena cava: a prospective comparison of venography and MRI. J Urol. 1989;142(4):943-7. (Level II/III evidence)
- Lim DJ, Carter MF. Computerized tomography in the preoperative staging of pulmonary metastases in patients with renal cell carcinoma. J Urol. 1993;150(4):1112-4. (Level III evidence)
- Campell RJ, Broaddus SB, Leadbetter GW Jr. Staging of renal carcinoma: cost effectiveness of routine pre-operative bone scans. Urology. 1985;25(3):326-9. (Level III evidence)
Further Reading
- Fritzsche PJ, Millar C. Multimodality approach to staging renal cell carcinoma. Urol Radiol. 1992;14:3-7. (Review article)
Information for Consumers
Information for Consumers
Information from this website |
Information from the Royal Australian and New Zealand College of Radiologists’ website |
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Consent to Procedure or Treatment Radiation Risks of X-rays and Scans Magnetic Resonance Imaging (MRI) |
Contrast Medium (Gadolinium versus Iodine) Iodine-Containing Contrast Medium Magnetic Resonance Imaging (MRI) Radiation Risk of Medical Imaging During Pregnancy Radiation Risk of Medical Imaging for Adults and Children |
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