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## Complete Summary

#### GUIDELINE TITLE

Follow-up of renal cell carcinoma.

#### BIBLIOGRAPHIC SOURCE(S)

Casalino DD, Francis IR, Baumgarten DA, Bluth EI, Bush WH Jr, Curry NS,
Israel GM, Jafri SZ, Kawashima A, Papanicolaou N, Remer EM, Sandler CM,
Spring DB, Fulgham P, Expert Panel on Urologic Imaging. Follow-up of
renal cell carcinoma. \[online publication\]. Reston (VA): American
College of Radiology (ACR); 2007. 5 p. \[60 references\]

#### GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates a previous version: Casalino DD, Choyke PL, Bluth
EI, Bush WH Jr, Francis IR, Jafri SZ, Kawashima A, Kronthal A, Older RA,
Papanicolaou N, Ramchandani P, Rosenfield AT, Sandler CM, Segal AJ,
Tempany C, Resnick MI, Expert Panel on Urologic Imaging. Follow-up of
renal cell carcinoma. \[online publication\]. Reston (VA): American
College of Radiology (ACR); 2005. 4 p. \[44 references\]

The appropriateness criteria are reviewed annually and updated by the
panels as needed, depending on introduction of new and highly
significant scientific evidence.

### COMPLETE SUMMARY CONTENT

 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 QUALIFYING STATEMENTS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

Renal cell carcinoma

#### GUIDELINE CATEGORY

Evaluation

#### CLINICAL SPECIALTY

Nephrology\
Nuclear Medicine\
Oncology\
Pulmonary Medicine\
Radiology\
Surgery

#### INTENDED USERS

Health Plans\
Hospitals\
Managed Care Organizations\
Physicians\
Utilization Management

#### GUIDELINE OBJECTIVE(S)

To evaluate the appropriateness of follow-up radiologic examinations for
patients with renal cell carcinoma

#### TARGET POPULATION

Patients with renal cell carcinoma

#### INTERVENTIONS AND PRACTICES CONSIDERED

1.  X-ray

    -   Chest

    -   Intravenous urography (IVU)

    -   Abdomen

    -   Radiographic survey, whole body

2.  Computed tomography (CT)

    -   Abdomen and pelvis

    -   Chest

    -   Head

3.  Magnetic resonance imaging (MRI)

    -   Abdomen and pelvis

    -   Head

4.  Fluorodeoxyglucose positron emission tomography (FDG-PET), whole
    body

5.  Ultrasound (US) kidney transabdominal view

6.  Nuclear medicine (NUC) bone scan whole body

#### MAJOR OUTCOMES CONSIDERED

Utility of radiologic procedures in follow-up evaluation of patients
with renal cell carcinoma

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

The guideline developer performed literature searches of peer-reviewed
medical journals, and the major applicable articles were identified and
collected.

#### NUMBER OF SOURCE DOCUMENTS

Not stated

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Weighting According to a Rating Scheme (Scheme Not Given)

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

Not stated

#### METHODS USED TO ANALYZE THE EVIDENCE

Systematic Review with Evidence Tables

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

One or two topic leaders within a panel assume the responsibility of
developing an evidence table for each clinical condition, based on
analysis of the current literature. These tables serve as a basis for
developing a narrative specific to each clinical condition.

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Expert Consensus (Delphi)

#### DESCRIPTION OF METHODS USED TO FORMULATE THE RECOMMENDATIONS

Since data available from existing scientific studies are usually
insufficient for meta-analysis, broad-based consensus techniques are
needed for reaching agreement in the formulation of the appropriateness
criteria. The American College of Radiology (ACR) Appropriateness
Criteria panels use a modified Delphi technique to arrive at consensus.
Serial surveys are conducted by distributing questionnaires to
consolidate expert opinions within each panel. These questionnaires are
distributed to the participants along with the evidence table and
narrative as developed by the topic leader(s). Questionnaires are
completed by the participants in their own professional setting without
influence of the other members. Voting is conducted using a scoring
system from 1 to 9, indicating the least to the most appropriate imaging
examination or therapeutic procedure. The survey results are collected,
tabulated in anonymous fashion, and redistributed after each round. A
maximum of three rounds is conducted and opinions are unified to the
highest degree possible. Eighty percent agreement is considered a
consensus. This modified Delphi technique enables individual, unbiased
expression, is economical, easy to understand, and relatively simple to
conduct.

If consensus cannot be reached by this Delphi technique, the panel is
convened and group consensus techniques are utilized. The strengths and
weaknesses of each test or procedure are discussed and consensus reached
whenever possible. If \"No consensus\" appears in the rating column,
reasons for this decision are added to the comment sections.

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

Not applicable

#### COST ANALYSIS

A formal cost analysis was not performed and published cost analyses
were not reviewed.

#### METHOD OF GUIDELINE VALIDATION

Internal Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

Criteria developed by the Expert Panels are reviewed by the American
College of Radiology (ACR) Committee on Appropriateness Criteria.

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

**ACR Appropriateness Criteria®**

**Clinical Condition: Follow-up of Renal Cell Carcinoma**

**Variant: Asymptomatic patient; no known metastases.**

  -----------------------------------------------------------------------------------
  **Radiologic          **Rating**   **Comments**                      **RRL\***
  Procedure**                                                          
  --------------------- ------------ --------------------------------- --------------
  X-ray chest           8            Not necessary if CT chest         Min
                                     performed.                        

  CT abdomen and pelvis 8            Particularly if primary was high  High
                                     stage and/or high grade.          

  MRI abdomen and       6            See comments regarding contrast   None
  pelvis                             in text under \"Anticipated       
                                     Expectations.\"                   

  CT chest              6                                              Med

  FDG PET, whole body   4            May have a role when CT and/or    High
                                     bone scan findings are equivocal. 

  US kidney             3                                              None
  transabdominal                                                       

  X-ray intravenous     2                                              Low
  urography                                                            

  NUC bone scan whole   2                                              Med
  body                                                                 

  MRI, head             1                                              None

  X-ray abdomen         1                                              Low

  CT, head              1                                              Low

  X-ray radiographic    1                                              Low
  survey whole body                                                    

  **[Rating                                                            **\*Relative
  Scale]{.underline}:                                                  Radiation
  1=Least appropriate,                                                 Level**
  9=Most appropriate**                                                 
  -----------------------------------------------------------------------------------

Note: Abbreviations used in the table are listed at the end of the
\"Major Recommendations\" field.

**Summary of Literature Review**

This narrative addresses appropriate imaging examinations to follow
patients who have been treated for renal cell carcinoma by radical
nephrectomy or nephron-sparing surgery. It specifically deals with
asymptomatic patients; it does not deal with imaging of nononcologic
complications of surgery; with patients undergoing systemic therapy for
known recurrent renal cell carcinoma; with patients in whom specific
symptoms, signs, or laboratory studies suggest recurrent malignancy at a
specific site; or with patients whose surgery is known to have left
residual tumor.

Follow-up is important for patients who have had radical or partial
nephrectomy for renal cell carcinoma. Although they may be thought to
have been initially cured, local or metastatic recurrences may develop
in 20% to 50% of them and require management. Solitary metastases may
occasionally be treated by resection. A nonspecific immune approach with
cytokines has been used to treat metastatic disease, yet the use of
these agents has been limited by their toxicity as well as generally
poor response rates. Recently, several new agents that inhibit vascular
endothelial growth factor signaling have shown significant antitumor
effects and meaningful clinical benefit. Imaging is essential in
evaluating the response to these therapies.

The anatomic location of recurrences clearly dictates the choice of
imaging modalities. The tumor may recur in the resection site,
especially if the primary is large, high grade, or has a higher tumor
(T) stage. The incidence of tumor recurrence in the resection site is
similar or only slightly higher in patients who had partial nephrectomy
compared to those who had radical nephrectomy. More commonly, however,
the tumor recurrence appears as distant metastases.

Several studies have suggested surveillance protocols based on patterns
of tumor recurrence, including where and when metastases occur, and the
primary tumor\'s size, stage, and nuclear grade at the time of
resection. For instance, the risk of metastatic disease after
nephrectomy increases with higher stage of the primary tumor. In
decreasing order of frequency, metastases most commonly appear in lung
(with or without mediastinal or hilar nodes), bone, the upper abdomen
(including the resection bed, adrenal gland, contralateral kidney and
liver), brain, and a multitude of other sites (including skin, spleen,
heart, diaphragm, gut, connective tissue, and pancreas).

Other characteristics of metastatic disease from renal cell carcinoma
are worth consideration. Most lung metastases are (at least early in
their history) asymptomatic. Metastases in thoracic nodes usually
indicate a very short survival. Most bone metastases are symptomatic at
the time of discovery; they can appear anywhere in the skeleton, but
frequently appear in the lumbar spine, thoracic spine, and ribs--that
is, the areas likely to be included in chest and abdomen examination.
Most recurrences appear within 2 to 3 years after the initial resection,
but they may not occur until decades later. Tumor recurrences tend to
occur earlier in patients with higher T stages, and those that appear
after a long interval appear to be associated with a better prognosis.
Therefore it may be argued either that routine follow-up should be
limited to only a few years (especially if the chosen modalities are
expensive) or that to halt follow-up after a brief period may deprive
those patients who might benefit most from treating recurrences of the
advantage of an early diagnosis.

Several stage-based surveillance protocols for renal cell carcinoma
after radical or partial nephrectomy have been proposed. They can be
summarized as follows:

-   **For T1 tumors**, as the risk of metastases is low, most
    surveillance protocols recommend that history, physical examination,
    laboratory tests, and a chest radiograph be obtained every 6 to 12
    months for 3 years and then yearly until year 5. Others have
    suggested no imaging if the tumor is less than 2.5 cm. Most
    protocols do not recommend surveillance with abdominal computed
    tomography (CT) for patients with T1 tumors.

-   **For T2 primary tumors**, most protocols recommend that history,
    physical examination, laboratory tests and a chest radiograph be
    obtained annually or every 6 months for 3 years, then annually
    thereafter till year 5. Protocols vary widely regarding the use of
    abdominal CT. Some do not recommend CT at all, while others
    recommend CT at year 2 and year 5. Still others recommend a CT every
    other year, or annually for 3 years following surgical removal, then
    annually thereafter.

-   **For T3 or T4 primary tumors**, most protocols recommend that
    history, physical examination, laboratory tests, and a chest
    radiograph be obtained every 6 months for a few years, then annually
    thereafter. The vast majority of protocols recommend abdominal CT,
    with most recommending more frequent (every 3 or 6 months) CT
    imaging for 3 years after surgery and less frequently (yearly or
    every other year) thereafter.

**Pulmonary Metastases**

Given the fact that pulmonary metastases are often asymptomatic, routine
imaging of the chest is usually performed. The major modalities used to
search for metastases in the chest are the chest x-ray and chest CT.
Certainly, if the chest x-ray is chosen and is positive, CT almost
inevitably follows in order to plan for and monitor the results of
further therapy. The chest x-ray is less expensive and less likely to
display incidental findings unrelated to metastatic disease. CT is more
likely to display metastases earlier (in particular, it is more likely
to demonstrate metastatic disease when there is just one lesion that
might be amenable to resection than when there are several) and is
probably more sensitive than chest x-ray in detecting metastases in
thoracic spine, ribs, bones of the shoulder, and nodes. But CT is also
more likely to display small granulomas that may masquerade as
metastases and require further workup. The extra yield from chest CT
compared to chest radiography is probably too small to warrant its use
in routine surveillance. While a few studies have shown
fluorine-18-2-fluoro-2-deoxy-D-glucose positron emission tomography
(FDG-PET) to be highly specific in detecting chest metastases, the
sensitivity is limited. No role for magnetic resonance imaging (MRI),
angiography, or ultrasound (US) has been claimed in screening for
metastases to the chest.

**Abdominal Recurrences**

Abdominal recurrences may occur at the surgical site or metastatic to
the liver, lymph nodes, adrenal glands, bones, etc. While a few studies
have argued against routine imaging of the abdomen in patients after
resection of low-stage tumors (T1 and certain T2 tumors), abdominal
surveillance is commonly performed with CT. CT is quite sensitive in
detecting metastases in the resection site, contralateral kidney,
adrenal glands, liver, and bones included in the examination. MRI should
be considered in place of CT in younger patients who will likely require
multiple scans and in patients with renal dysfunction or a history of
allergy to iodinated contrast. Plain radiography is likely to be
insensitive for all but the largest of masses and bone metastases.
FDG-PET can be a useful adjunct to CT or MRI, particularly when a local
recurrence is suspected in a renal fossa that may have postoperative and
post-radiation changes. Performing separate nuclear medicine
liver-spleen, bone, and renal scans is not practical. Angiography is too
invasive. Urography is likely to be less sensitive than CT; it may be
falsely negative in patients with small intrarenal masses and it is
likely to miss all but the largest extrarenal masses. US has
demonstrated some success in detecting intra-abdominal recurrences, but
it has never been shown to be as sensitive as CT, and it is likely to be
less sensitive in detecting small resection bed metastases, especially
if the nephrectomy has been performed on the left side and if loops of
gut occupy the surgical site.

**Follow-up of Renal Cell Carcinoma after Ablative Therapies**

Energy ablative therapies, such as cryoablation and radiofrequency (RF)
ablation, are increasingly used in treating of small renal cell
carcinomas as an alternative to partial nephrectomy. These therapies
have been shown to be effective and safe. Postablative CT and MRI play
an important role in the evaluation of the ablation zone, surveillance
for residual or recurrent tumor, and identification of procedure-related
complications.

A recent multi-institutional study reported that 63 of 616 patients
(10.2%) were found to have residual or recurrent tumor after primary
ablation. Residual tumor was defined as enhancement in the vicinity of
the treated tumor on the first imaging study after the ablative
procedure, and recurrent tumor was defined as enhancement after an
initially negative imaging study. Thirty-seven of 46 patients who
received salvage ablative therapy for residual or recurrent disease had
no further evidence of disease over a mean follow-up period of two
years. Seventy percent of the initial treatment failures were detected
within the first 3 months after therapy, and 92% were detected within
the first 12 months. The proposed surveillance protocol consisted of a
minimum of 3 to 4 imaging studies (CT or MRI) in year one after ablative
therapy, with studies being performed at months 1, 3, 6 (optional) and
12. The CT or MRI should be a dedicated renal exam using thin cuts and
precontrast and postcontrast imaging. The study did not make a specific
recommendation for surveillance beyond the first year; although, all the
participating institutions reported follow-up imaging with CT or MRI in
the range of every 6 to 12 months after year one. The required duration
of follow-up is still unknown.

**Osseous Metastases**

Surveillance for the appearance of metastases to the skeleton might be
done by serial radionuclide bone scans, or it might not be done at all
unless the patient develops specific symptoms. Most authors do not
suggest routine bone scanning to search for metastases without symptoms,
because the vast majority of bone metastases are symptomatic and bone
metastases are not curable. When a bone metastasis is suspected, a bone
scan is preferable to MRI or CT because it can survey the entire
skeleton. If the bone scan is positive, a radiograph might be considered
to exclude pending fracture. Identification of bone metastases may
facilitate treatment for pain relief and prevention of pathologic
fracture.

Relatively little has been written regarding the use of radiography or
scintigraphy to monitor patients in the postoperative phase. FDG-PET may
have a role when CT and/or bone scan findings are equivocal. FDG-PET may
reveal bone metastases not detected on bone scan, but false negative
results have also been reported.

**Brain Metastases**

There has been no literature that supports employing routine imaging of
the brain to search for metastases from renal cell carcinoma in
asymptomatic patients.

**Summary**

Tumor recurrences, whether metastatic or local, are not uncommon after
resection of localized renal cell carcinoma. The intensity and length of
follow-up in these patients are largely dependent on the stage of the
primary tumor. The follow-up generally includes a history and physical
examination, CBC, LFTs, and chest radiography. While there is no clear
consensus regarding the timing of abdominal CT in routine surveillance,
abdominal CT is generally included in the follow-up evaluation of
patients after resection. The literature does not support the routine
use of bone scans or brain imaging in asymptomatic patients. FDG-PET
appears to be a useful adjunct to conventional imaging.

**Anticipated Exceptions**

Nephrogenic systemic fibrosis (NSF, also known as nephrogenic fibrosing
dermopathy) was first identified in 1997 and has recently generated
substantial concern among radiologists, referring doctors and lay
people. Until the last few years, gadolinium-based MR contrast agents
were widely believed to be almost universally well tolerated, extremely
safe and non-nephrotoxic, even when used in patients with impaired renal
function. All available experience suggests that these agents remain
generally very safe, but recently some patients with renal failure who
have been exposed to gadolinium contrast agents (the percentage is
unclear) have developed NSF, a syndrome that can be fatal. Further
studies are necessary to determine what the exact relationships are
between gadolinium-containing contrast agents, their specific components
and stoichiometry, patient renal function and NSF. Current theory links
the development of NSF to the administration of relatively high doses
(e.g., \>0.2 mM/kg) and to agents in which the gadolinium is least
strongly chelated. The FDA has recently issued a \"black box\" warning
concerning these contrast agents
(<http://www.fda.gov/cder/drug/InfoSheets/HCP/gcca_200705HCP.pdf>).

This warning recommends that, until further information is available,
gadolinium contrast agents should not be administered to patients with
either acute or significant chronic kidney disease (estimated GFR \<30
mL/min/1.73m^2^), recent liver or kidney transplant or hepato-renal
syndrome, unless a risk-benefit assessment suggests that the benefit of
administration in the particular patient clearly outweighs the potential
risk(s).

**Abbreviations**

-   CT, computed tomography

-   FDG PET, fluorodeoxyglucose positron emission tomography

-   Med, medium

-   Min, minimal

-   MRI, magnetic resonance imaging

-   NUC, nuclear medicine

-   US, ultrasound

#### CLINICAL ALGORITHM(S)

None provided

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The recommendations are based on analysis of the current literature and
expert panel consensus.

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

Selection of appropriate radiologic imaging procedures for evaluation of
patients with renal cell carcinoma

#### POTENTIAL HARMS

-   Urography is likely to be less sensitive than computed tomography
    (CT) in the evaluation of abdominal recurrences; it may be falsely
    negative in patients with small intrarenal masses, and it is likely
    to miss all but the largest extrarenal masses.

-   While fluorodeoxyglucose positron emission tomography (FDG PET) may
    reveal bone metastases not detected on bone scan, false negative
    results have also been reported.

-   The relative radiation level is high for CT of the abdomen and
    pelvis and FDG-PET whole body; medium for CT of the chest and NUC
    bone scan whole body; and low for X-ray intravenous urography, X-ray
    of the abdomen, and X-ray radiographic survey of the whole body, and
    CT of the head.

-   Some patients with renal failure who have been exposed to gadolinium
    contrast agents (the percentage is unclear) have developed
    nephrogenic systemic fibrosis, a syndrome that can be fatal.

-   Until further information is available, gadolinium contrast agents
    should not be administered to patients with either acute or
    significant chronic kidney disease (estimated GFR \<30
    mL/min/1.73m^2^), recent liver or kidney transplant or hepato-renal
    syndrome, unless a risk-benefit assessment suggests that the benefit
    of administration in the particular patient clearly outweighs the
    potential risk(s).

### QUALIFYING STATEMENTS

#### QUALIFYING STATEMENTS

An American College of Radiology (ACR) Committee on Appropriateness
Criteria and its expert panels have developed criteria for determining
appropriate imaging examinations for diagnosis and treatment of
specified medical condition(s). These criteria are intended to guide
radiologist, radiation oncologist, and referring physicians in making
decisions regarding radiologic imaging and treatment. Generally, the
complexity and severity of a patient\'s clinical condition should
dictate the selection of appropriate imaging procedures or treatments.
Only those exams generally used for evaluation of the patient\'s
condition are ranked. Other imaging studies necessary to evaluate other
co-existent diseases or other medical consequences of this condition are
not considered in this document. The availability of equipment or
personnel may influence the selection of appropriate imaging procedures
or treatments. Imaging techniques classified as investigational by the
U.S. Food and Drug Administration (FDA) have not been considered in
developing these criteria; however, study of new equipment and
applications should be encouraged. The ultimate decision regarding the
appropriateness of any specific radiologic examination or treatment must
be made by the referring physician and radiologist in light of all the
circumstances presented in an individual examination.

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

An implementation strategy was not provided.

#### IMPLEMENTATION TOOLS

Personal Digital Assistant (PDA) Downloads

For information about
[availability](#identifying-information-and-availability), see the
\"Availability of Companion Documents\" and \"Patient Resources\" fields
below.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Living with Illness

#### IOM DOMAIN

Effectiveness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

Casalino DD, Francis IR, Baumgarten DA, Bluth EI, Bush WH Jr, Curry NS,
Israel GM, Jafri SZ, Kawashima A, Papanicolaou N, Remer EM, Sandler CM,
Spring DB, Fulgham P, Expert Panel on Urologic Imaging. Follow-up of
renal cell carcinoma. \[online publication\]. Reston (VA): American
College of Radiology (ACR); 2007. 5 p. \[60 references\]

#### ADAPTATION

Not applicable: The guideline was not adapted from another source.

#### DATE RELEASED

1996 (revised 2007)

#### GUIDELINE DEVELOPER(S)

American College of Radiology - Medical Specialty Society

#### SOURCE(S) OF FUNDING

American College of Radiology (ACR) provided the funding and the
resources for these ACR Appropriateness Criteria®.

#### GUIDELINE COMMITTEE

Committee on Appropriateness Criteria, Expert Panel on Urologic Imaging

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

*Panel Members*: David D. Casalino, MD; Isaac R. Francis, MD; Deborah A.
Baumgarten, MD; Edward Bluth, MD; William H. Bush, Jr., MD; Nancy S.
Curry, MD; Gary M. Israel, MD; S. Zafar H. Jafri, MD; Akira Kawashima,
MD, Nicholas Papanicolaou, MD; Erick M. Remer, MD; Carl M. Sandler, MD;
David B. Spring, MD; Pat Fulgham, MD

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

Not stated

#### GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates a previous version: Casalino DD, Choyke PL, Bluth
EI, Bush WH Jr, Francis IR, Jafri SZ, Kawashima A, Kronthal A, Older RA,
Papanicolaou N, Ramchandani P, Rosenfield AT, Sandler CM, Segal AJ,
Tempany C, Resnick MI, Expert Panel on Urologic Imaging. Follow-up of
renal cell carcinoma. \[online publication\]. Reston (VA): American
College of Radiology (ACR); 2005. 4 p. \[44 references\]

The appropriateness criteria are reviewed annually and updated by the
panels as needed, depending on introduction of new and highly
significant scientific evidence.

#### GUIDELINE AVAILABILITY

Electronic copies: Available in Portable Document Format (PDF) from the
[American College of Radiology (ACR) Web
site](http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonUrologicImaging/FollowUpofRenalCellCarcinomaDoc5.aspx).

ACR Appropriateness Criteria® *Anytime*, *Anywhere*™ (PDA application).
Available from the [ACR Web
site](http://www.acr.org/SecondaryMainMenuCategories/ACRStore/FeaturedCategories/QualityandSafety/ac_pda.aspx).

Print copies: Available from the American College of Radiology, 1891
Preston White Drive, Reston, VA 20191. Telephone: (703) 648-8900.

#### AVAILABILITY OF COMPANION DOCUMENTS

The following are available:

-   ACR Appropriateness Criteria®. Background and development. Reston
    (VA): American College of Radiology; 2 p. Electronic copies:
    Available in Portable Document Format (PDF) from the [American
    College of Radiology (ACR) Web
    site](http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria.aspx).

-   ACR Appropriateness Criteria®. Relative radiation level information.
    Reston (VA): American College of Radiology; 2 p. Electronic copies:
    Available in Portable Document Format (PDF) from the [American
    College of Radiology (ACR) Web
    site](http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/RRLInformation.aspx).

#### PATIENT RESOURCES

None available

#### NGC STATUS

This NGC summary was completed by ECRI on March 6, 2006. This NGC
summary was updated by ECRI Institute on November 16, 2007.

#### COPYRIGHT STATEMENT

Instructions for downloading, use, and reproduction of the American
College of Radiology (ACR) Appropriateness Criteria® may be found on the
[ACR Web
site](http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/ACRAppropriatenessCriteriaTermsandConditionsDoc1.aspx).

### DISCLAIMER

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Date Modified: 11/10/2008