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Oh and Sung: Current MR Imaging of Renal Cell Carcinoma
Uroradiology
Review Article

Journal of the Korean Society of Radiology 2016; 75(2): 77-91.

Published online: 27 July 2016

DOI: https://doi.org/10.3348/jksr.2016.75.2.77

Current MR Imaging of Renal Cell Carcinoma

Saelin Oh, MD, Deuk Jae Sung, MD

Department of Radiology, Anam Hospital, Korea University College of Medicine, Seoul, Korea.

Corresponding author: Deuk Jae Sung, MD. Department of Radiology, Anam Hospital, Korea University College of Medicine, 73 Inchon-ro, Seongbuk-gu, Seoul 02841, Korea. Tel. 82-2-920-5578 Fax. 82-2-929-3796, urorad@korea.ac.kr

Received 19 January 2016       Revised 15 March 2016       Accepted 30 March 2016

Copyright © 2016 The Korean Society of Radiology

(open-access):

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Renal cell carcinoma (RCC) consists of approximately 85–90% of renal masses, and its incidence is increasing due to widespread use of modern imaging modalities such as ultrasonography or computed tomography. Computed tomography has served an important role in the diagnosis and staging of RCC; however, recent advances in magnetic resonance imaging (MRI) techniques have considerably improved our ability to predict tumor biology beyond the morphologic assessment. Multiparametric MRI protocols include standard sequences tailored for the morphologic evaluation and acquisitions that provide information about the tumor microenvironment such as diffusion-weighted imaging and dynamic contrast-enhanced MRI. The role of multiparametric MRI in the evaluation of RCC now extends to preoperative characterization of RCC subtypes, histologic grade, and quantitative assessment of tumor response to targeted therapies in patients with metastatic disease. Herein, the clinical applications and recent advances in MRI applied to RCC are reviewed along with its merits and demerits. We aimed to review MRI techniques and image analysis that can improve the management of patients with RCC. Familiarity with the advanced MRI techniques and various imaging findings of RCC would also facilitate optimal clinical recommendations for patients.

Keywords: Renal Cell Carcinoma, Magnetic Resonance Imaging

Figures and Tables

Fig. 1

61-year-old woman with clear cell renal cell carcinoma in right kidney.

A. On T2-weighted MR image, the tumor (arrow) in right kidney shows heterogeneous hyperintensity, as compared to the normal cortex.
B. Fat-suppressed axial T1-weighted image shows the tumor (arrow) as slightly hypointense.
C, D. Contrast-enhanced fat-suppressed axial T1-weighted images show heterogeneous enhancement in the tumor (arrow) at corticomedullary phase (C) and wash-out in the tumor at nephrographic phase (D).
jksr-75-77-g001
Fig. 2

56-year-old man with papillary cell renal cell carcinoma in right kidney.

A. Axial T2-weighted image shows a small hypointense tumor (arrow) in right kidney.
B. Fat-suppressed axial T1-weighted image also shows the tumor (arrow) as isointense.
C. Contrast-enhanced fat-suppressed axial T1-weighted image shows poor enhancement in the tumor (arrow) at corticomedullary phase.
jksr-75-77-g002
Fig. 3

76-year-old woman with angiomyolipoma in left kidney.

A. On T2-weighted MR image, the tumor (arrow) in left kidney shows hypointensity, as compared to the normal cortex.
B. Fat-suppressed axial T1-weighted image also shows the tumor (arrow) as isointense.
C. Contrast-enhanced fat-suppressed axial T1-weighted image shows heterogeneous enhancement in the tumor at corticomedullary phase.
D. Diffusion-weighted image acquired at b = 800 sec/mm2 shows the tumor (arrow) as slightly hyperintense.
E. Apparent diffusion coefficient map shows obvious diffusion restriction in the tumor (arrow).
jksr-75-77-g003
Fig. 4

44-year-old woman with angiomyolipoma in right kidney.

A, B. In-phase MR image (A) shows the tumor (arrow) as slightly hyperintense and out-of-phase MR image (B) shows obvious signal intensity drop in the tumor (arrow).
C. Fat-suppressed axial T1-weighted image shows the tumor (arrow) as hypointense.
jksr-75-77-g004
Fig. 5

82-year-old man with clear cell renal cell carcinoma in left kidney.

A. Axial T2-weighted image shows a heterogeneously hyperintense tumor (arrow) in left kidney.
B. Contrast-enhanced fat-suppressed axial T1-weighted image shows a heterogeneously enhancing tumor (arrow) in left kidney at corticomedullary phase.
C, D. In-phase MR image (C) shows the tumor (arrow) as isointense and out-of-phase MR image (D) shows focal signal intensity drop (arrow) in the tumor.
jksr-75-77-g005
Fig. 6

71-year-old woman with chromophobe renal cell carcinoma in left kidney.

A. Axial T2-weighted image shows a small and heterogeneously hypointense tumor (arrow) in left kidney.
B. Fat-suppressed axial T1-weighted image shows the tumor (arrow) as isointense.
C. Contrast-enhanced fat-suppressed axial T1-weighted image shows poor enhancement in the tumor (arrow) at corticomedullary phase.
jksr-75-77-g006
Fig. 7

47-year-old woman with clear cell renal cell carcinoma in left kidney.

A. Axial T2-weighted image shows a heterogeneously hyperintense tumor in left kidney.
B. Contrast-enhanced fat-suppressed axial T1-weighted image shows heterogeneous enhancement in the tumor at corticomedullary phase.
C. Diffusion-weighted image acquired at b = 800 sec/mm2 shows the tumor (arrow) as heterogeneously hyperintense.
D. Apparent diffusion coefficient map shows obvious diffusion restriction in the tumor (arrow).
jksr-75-77-g007
Fig. 8

71-year-old man with papillary cell renal cell carcinoma in right kidney.

A. On T2-weighted MR image, the tumor (arrow) in right kidney shows hypointensity, as compared to the normal cortex.
B. Contrast-enhanced fat-suppressed axial T1-weighted image shows poor enhancement in the tumor (arrow) at corticomedullary phase.
C. Diffusion-weighted image acquired at b = 800 sec/mm2 shows the tumor (arrow) as hyperintense.
D. Apparent diffusion coefficient map shows diffusion restriction in the tumor (arrow).
jksr-75-77-g008
Fig. 9

42-year-old woman with Fuhrman grade II clear cell renal cell carcinoma in left kidney and 66-year-old man with Fuhrman grade IV clear cell renal cell carcinoma in left kidney.

A, B. The tumor (arrows) confirmed as Fuhrman grade II clear cell renal cell carcinoma shows subtle hyperintensity on diffusion-weighted image acquired at b = 800 sec/mm2 (A) and diffusion restriction on apparent diffusion coefficient map (B). The calculated apparent diffusion coefficient value of the Fuhrman grade II clear cell renal cell carcinoma is 1.15 × 10-3 mm2/sec.
C, D. The tumor (arrows) confirmed as Fuhrman grade IV clear cell renal cell carcinoma shows heterogeneous hyperintensity on diffusion-weighted image acquired at b = 800 sec/mm2 (C) and prominent diffusion restriction on apparent diffusion coefficient map (D). The calculated apparent diffusion coefficient value of the Fuhrman grade IV clear cell renal cell carcinoma is 0.91 × 10-3 mm2/sec.
jksr-75-77-g009
Fig. 10

48-year-old man with clear cell renal cell carcinoma in left kidney.

A. Coronal T2-weighted image shows a heterogeneously hyperintense tumor in left kidney with thrombus (arrow) in left renal vein.
B. Contrast-enhanced fat-suppressed coronal T1-weighted image shows heterogeneous enhancement in the thrombus (arrow) in left renal vein.
The enhancing thrombus was confirmed as tumor thrombus at surgery.
jksr-75-77-g010
Fig. 11

54-year-old man with clear cell renal cell carcinoma treated initially by renal cryoablation.

A, B. Two years after cryoablation, the treated tumor (arrows) shows hypointensity on axial T2-weighted image (A) and no enhancement on contrast-enhanced axial T1-weighted image (B).
C, D. Four years after cryoablation, a focal and subtle hyperintensity (arrow) is newly seen at the treated tumor on axial T2-weighted image (C), and a distinct nodular enhancement (arrow) is demonstrated at the newly developed, focal hyperintensity on contrast-enhanced fat-suppressed axial T1-weighted image (D). The nodular enhancement was confirmed as recurred clear cell renal cell carcinoma, which was treated again by radiofrequency ablation.
jksr-75-77-g011
Fig. 12

54-year-old woman with tuberous sclerosis and clear cell renal cell carcinoma treated initially by radical nephrectomy.

A. Contrast-enhanced axial CT image shows a heterogeneously enhancing mass suggesting tumor recurrence at previous left nephrectomy site.
B, C. Three months after targeted therapy with antiangiogenetic agent, the recurred tumor shows heterogeneous hyperintensity on fat-suppressed axial T1-weighted image (B) and poor enhancement on contrast-enhanced fat-suppressed axial T1-weighted image (C). Angiomyolipoma showing heterogeneous enhancement is seen in upper pole of right kidney.
jksr-75-77-g012
Table 1

TNM Classification for Renal Cell Carcinoma (UICC/AJCC, 2010)

jksr-75-77-i001
Primary tumors (T)
 TX: primary tumor cannot be assessed
 T0: no evidence of primary tumor
 T1: tumor ≤ 7 cm in greatest dimension, limited to the kidney
  T1a: tumor ≤ 4 cm in greatest dimension, limited to the kidney
  T1b: tumor > 4 cm but ≤ 7 cm in greatest dimension, limited to the kidney
 T2: tumor > 7 cm in greatest dimension, limited to the kidney
  T2a: tumor > 7 cm but ≤ 10 cm in greatest dimension, limited to the kidney
  T2b: tumor > 10 cm, limited to the kidney
 T3: tumor extends into major veins or perinephric tissues but not into the ipsilateral adrenal gland and not beyond the Gerota fascia
  T3a: tumor grossly extends into the renal vein or its segmental (muscle-containing) branches, or tumor invades perirenal and/or renal sinus fat but not beyond the Gerota fascia
  T3b: tumor grossly extends into the vena cava below the diaphragm
  T3c: tumor grossly extends into the vena cava above the diaphragm or invades the wall of the vena cava
 T4: tumor invades beyond the Gerota fascia (including contiguous extension into the ipsilateral adrenal gland)
Regional lymph node (N)
 NX: regional lymph nodes cannot be assessed
 N0: no regional lymph node metastasis
 N1: metastasis in regional lymph node(s)
Distant metastasis (M)
 M0: no distant metastasis
 M1: distant metastasis

AJCC = American Joint Committee on Cancer, UICC = Union International Contra la Cancrum

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