Preoperative imaging in renal cell cancer

Renal cell cancer (RCC) represents the fifth most common cancer in men, with a rising incidence. Radical cancer surgery remains the only curative treatment in localized and advanced RCC. Therefore, preoperative imaging is most important for the planning of the surgical approach and strategy. The aim of any preoperative imaging in RCC is to differentiate benign from malignant lesions, to adequately assess tumor size, localization and organ confinement, to identify lymph node and/or visceral metastases, and to reliably predict the presence and extent of any thrombus of the vena cava. It is our aim to review the current status of preoperative imaging modalities in RCC. Computed tomography (CT) remains the most appropriate imaging modality to differentiate benign from malignant lesions. Although RCC can appear as iso-, hyper- or hypodense lesions on native CT scans, it usually demonstrates a significant contrast enhancement of about 115 HU and intratumoral areas of necrosis following the intravenous application of contrast medium. Benign masses such as renal oncocytoma are most often homogenous lesions exhibiting hypodensity compared to the normal renal parenchyma following the i.v. application of contrast dye. CT accurately predicts the tumor size with only a 0.5 cm difference as compared to the pathological size of the lesion. The identification of lymph node metastases still remains a problem since the limiting size is 4 mm and CT will result in a false negative rate of about 10%, especially in the presence of micrometastases; the false positive rate of 3 - 43% is mainly due to reactive hyperplasia. New technologies, such as the multidetector CT with thin collimation and multiplanar reformatting, might result in a diagnostic improvement. The involvement of the adrenal gland can be accurately predicted by CT scans or MRI, allowing an adrenal sparing approach in the case of unsuspicious findings. The detection of visceral metastases appears to be crucial since it has been shown that even patients with metastatic disease might benefit from radical nephrectomy followed by systemic immunotherapy in the case of a good performance status, and the presence of lymph node and pulmonary metastases only. Involvement of the renal vein and the vena cava with tumor thrombus formation will change the surgical strategy. Preoperatively, the presence and the cranial extent of the thrombus need to be known in order to plan the surgical approach. With regard to the extent of renal vein thrombi, a three phase helical CT scan is most appropriate; for vena caval thrombi only a MRI examination is able to accurately identify any infra- or suprahepatic as well as intracardial extension of the thrombus. The identification of multifocal lesions remains another unsolved problem in preoperative imaging techniques for RCC. Compared to the patho-histological analysis of nephrectomy specimens, neither ultrasonography, color duplex sonography nor regular CT scans are able to identify multifocal lesions with acceptable sensitivity and specificity. The evaluation of unenhanced CT scans together with the enhanced corticomedullary and the nephrogenic phase result in a 100% sensitivity and might represent a valuable option. Angiography has basically been abandoned from the armory of routine imaging techniques. It has, however, a current role in terms of the embolization of large tumors to reduce intraoperative blood loss, and in the palliative management of pain and bleeding due to RCC not amenable to surgery. Finally, we present a diagnostic algorithm for the most informative imaging techniques in the evaluation of RCC.