Evaluation
High-quality computed tomography (CT) scan both prior to and
following administration of intravenous contrast remains the radiologic
modality for choice to work up a renal mass. Magnetic resonance imaging (MRI)
may be useful in the setting of locally advanced disease, venous involvement,
renal insufficiency, or allergy to IV contrast. However, due to concerns
related to a potential link between nephrogenic systemic fibrosis (NSF) and
gadolinium exposure, routine use of MRI is not advocated, and MRI should be
reserved for patients who have had a previous allergic reaction to contrast
(American Urological Association [AUA], 2009). Color flow Doppler imaging may
be useful in detecting renal vein/vena cava involvement. Metastatic evaluation
includes CT of the abdomen and pelvis, chest X-ray, and liver function tests.
If chest xray is abnormal, then a CT of the chest is warranted. Bone scan
should be ordered if there is an elevation of alkaline phosphatase and/or bone
pain (Seaman, Goluboff, Ross, & Sawczuk, 1996).
The role of biopsy for localized renal tumor has evolved.
Initially, renal biopsy was believed to offer no significant benefit except in
patients with metastases in which a diagnosis was needed. However, more
recently, the role of renal biopsy has been re-examined. This is supported by
the fact that about 20% of clinical Stage 1 renal masses may be benign, and
improvements in accuracy and safety of biopsy, related to better CT and
MRI-guided techniques, have resulted in a reconsideration of the role of biopsy
(Kummerlin et al., 2008; Lane et al., 2007; Lebret et al., 2007; Oda et al.,
2001; Pahernik, Ziegler, Roos, Melchior, & Thuroff, 2007; Remzi et al.,
2006; Salamanca et al., 2007; Schmidbauer et al., 2008; Somani et al., 2007;
Volpe et al., 2007; Zagoria, Gasser, Leyendecker, Bechtold, & Dyer, 2007).
In a review of the pathology and radiology databases of a single tertiary
referral from 2000 to 2009, Ramsey and colleagues (2010) suggested that renal
biopsy is no longer simply for diagnostic dilemmas in patients with renal
masses. Older adult patients under consideration for targeted therapies and
unfit for cytoreductive nephrectomy have established a role for renal biopsy in
confirming the diagnosis prior to treatment (Ramsey et al., 2010).
