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## Complete Summary

#### GUIDELINE TITLE

Renal cell carcinoma staging.

#### BIBLIOGRAPHIC SOURCE(S)

Curry NC, Francis IR, Baumgarten DA, Bluth EI, Bush WH Jr, Casalino DD,
Israel GM, Jafri SZ, Kawashima A, Papanicolaou N, Remer EM, Sandler CM,
Spring DB, Fulgham P, Expert Panel on Urologic Imaging. Renal cell
carcinoma staging. \[online publication\]. Reston (VA): American College
of Radiology (ACR); 2007. 8 p. \[48 references\]

#### GUIDELINE STATUS

This is the current release of the guideline.

It updates a previous published version: Choyke PL, Bluth EI, Bush WH
Jr, Casalino DD, 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. Renal cell
carcinoma staging. \[online publication\]. Reston (VA): American College
of Radiology (ACR); 2005. 5 p. \[40 references\]

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\
 CONTRAINDICATIONS\
 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

Diagnosis\
Evaluation\
Screening

#### CLINICAL SPECIALTY

Family Practice\
Internal Medicine\
Nephrology\
Nuclear Medicine\
Oncology\
Radiation Oncology\
Radiology\
Urology

#### INTENDED USERS

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

#### GUIDELINE OBJECTIVE(S)

To evaluate the appropriateness of radiologic examinations in the
staging of renal cell carcinoma

#### TARGET POPULATION

Adult patients with renal cell carcinoma

#### INTERVENTIONS AND PRACTICES CONSIDERED

1.  X-ray

    -   Chest

    -   Radiographic survey, whole body

2.  Computed tomography (CT), chest

3.  Computed tomography angiography (CTA), abdomen

4.  Magnetic resonance angiography (MRA), abdomen

5.  Ultrasound (US), abdomen

6.  Invasive (INV) angiography, kidney

7.  INV venacavography inferior

8.  Nuclear medicine (NUC) bone scan, whole body

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

#### MAJOR OUTCOMES CONSIDERED

Utility of radiologic procedures in staging of 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 participants in their own professional setting without
influence of the other members. Voting is conducted using a scoring
system from 1-9, 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 the 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: Renal Cell Carcinoma Staging**

**Variant 1: Tumor \<3 cm.**

  -----------------------------------------------------------------------------------
  **Radiologic          **Rating**   **Comments**                      **RRL\***
  Procedure**                                                          
  --------------------- ------------ --------------------------------- --------------
  CTA abdomen           9                                              Med

  X-ray chest           8            Asymptomatic patient.             Min

  MRA abdomen           8            See comments regarding contrast   None
                                     in text under \"Anticipated       
                                     Expectations.\"                   

  CT chest              5            Patient with solitary nodule on   Med
                                     chest X-ray or respiratory        
                                     symptoms.                         

  US abdomen            4            More appropriate in patients with None
                                     contrast sensitivity or renal     
                                     insufficiency.                    

  MRI head              1                                              None

  FDG-PET whole body    1                                              High

  NUC bone scan whole   1                                              Med
  body                                                                 

  INV angiography       1                                              IP
  kidney                                                               

  INV venacavography    1                                              IP
  inferior                                                             

  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 tables are listed at the end of the
\"Major Recommendations\" field.

**Variant 2: Tumor \>3 cm.**

  -----------------------------------------------------------------------------------
  **Radiologic          **Rating**   **Comments**                      **RRL\***
  Procedure**                                                          
  --------------------- ------------ --------------------------------- --------------
  CTA abdomen           9                                              Med

  X-ray chest           8                                              Min

  CT chest              8            Can identify subtle pulmonary     Med
                                     nodules, mediastinal              
                                     lymphadenopathy, bone and         
                                     subcutaneous metastases. Confirms 
                                     or excludes metastases seen on    
                                     chest x-ray.                      

  MRA abdomen           8            See comments regarding contrast   None
                                     in text under \"Anticipated       
                                     Expectations.\"                   

  FDG-PET whole body    4                                              High

  US abdomen            3                                              None

  INV venacavography    3                                              IP
  inferior                                                             

  NUC bone scan whole   3            More appropriate if tumor \>7 cm  Med
  body                               or locally advanced; if bone pain 
                                     present.                          

  MRI head              3            More appropriate if tumor \>7 cm  None
                                     or locally advanced; or if        
                                     neurologic symptoms present.      

  INV angiography       2            Appropriate as part of renal      IP
  kidney                             tumor embolization prior to       
                                     surgery in hypervascular tumors   
                                     to reduce blood loss at surgery   
                                     and for palliation of hematuria   
                                     in inoperable tumors.             

  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 tables are listed at the end of the
\"Major Recommendations\" field.

**Summary of Literature Review**

Renal cell carcinoma (RCC) accounts for 2% to 3% of all visceral
malignancies. Approximately 36,000 new cases are diagnosed per year in
the U.S., resulting in approximately 12,500 deaths. The incidence in men
is nearly twice that in women. Metastatic disease at presentation varies
with the patient population but typically occurs in about one-third of
patients. The most common sites of distant metastases in descending
order are the lung, bone, skin, liver, and brain, or in multiple sites.

The traditional treatment for RCC is radical nephrectomy, which involves
node dissection and complete removal of the kidney and Gerota\'s fascia.
Nephron-sparing surgery is increasingly used for small tumors. Prognosis
is related to tumor size and stage. Robson\'s staging system (See
Appendix 1 in the original guideline document.) was introduced in the
1960s and was much less complex than the TNM system first introduced in
1978 and revised in 1987 and 1997.

The Robson classification has significant limitations in that venous
tumoral involvement and lymph node metastases are grouped in the same
stage. There are now strong advocates for use of the revised 1997 TNM
staging system (See Appendix 2 and 3 in the original guideline
document), which is regarded as more accurate and of greater prognostic
value. Two significant changes from the 1987 TMN system reflect the
importance of tumor size and the extent of inferior vena cava (IVC)
involvement. Tumors larger than 7 cm have been upgraded to T2 lesions.
For surgical planning of partial elective nephrectomy, further division
of T1 tumors into T1a and T1b was added, with a 4.0-cm cutoff separating
them, for lesions confined to the kidney. The other significant change
in the TNM system regards the extent of IVC involvement. Tumor involving
the renal vein with or without IVC involvement below the diaphragm is
considered T3b disease, whereas tumor involving the IVC above the
diaphragm is classified as T3c.

Approximately 33% of RCCs present in stage I, 10% in stage II, 25% in
stage III, and 33% in stage IV. With recent advancements in diagnosis
and treatment, median 5-year cancer-specific survival rates have
improved to 90% to 95% for stage I, 75% to 85% for stage II, 60% to 70%
for stage III, and 20% to 30% for stage IV.

Prognosis is related to the size of the primary tumor as well. In one
large study, patients with tumors \<2.5 cm had a 100% 5-year survival
rate, whereas tumors \>10 cm in diameter yielded a median survival rate
of 27% at 5 years. Only 5% to 10% of patients present with the classic
triad of flank mass, hematuria, and pain. Since the widespread use of
ultrasound (US), computed tomography (CT), and magnetic resonance
imaging (MRI), RCCs are increasingly discovered when they are small and
therefore at lower stage. Although these incidentally discovered small
tumors have a much better prognosis than symptomatic tumors
nonaggressive biologic behavior cannot be assumed. In one study of 50
lesions smaller than 3 cm, 38% had extension outside the renal capsule
with T3/T4 disease. In another series, 12% of 318 T1 tumors had higher
staging due to nodal and distant metastases this was likely related to
other factors such as tumor subtype and nuclear grade.

Preoperative staging is important to the surgeon in planning the
procedure. Tumor size is accurately determined by CT, MRI, and US.
Perinephric tumor extension (T3a) is difficult to discriminate from
nonspecific perinephric stranding from edema, vascular engorgement, or
fibrosis. High-resolution CT using thin sections (\~1 mm) can
demonstrate perinephric stranding with 96% sensitivity, 93% specificity,
and 95% accuracy, although false positives can be problematic. This
determination is often not critical since the tumor and perinephric fat
are usually removed at the time of radical nephrectomy. The presence of
T3a disease should be excluded, however, if nephron-sparing surgery is
planned. CT shows a 100% negative predictive value for T3a disease
involving the adrenal gland. Breath-hold MRI showing lack of perinephric
fat involvement has high negative predictive value and predicts whether
a tumor can be removed by nephron-sparing surgery. In a study of 73 RCCs
one group of investigators showed that the presence of a pseudocapsule
on MRI had an accuracy of 93% for clear-cell carcinoma in separating
T1/T2 tumors from T3a tumors.

Tumor extends into the renal vein in 20% of cases and into renal vein
and IVC in 10%, yet with proper surgical treatment, patients with T3b or
T3c disease may have survival rates similar to those for stages 1 and II
disease. Not only must the involvement of the renal veins and inferior
vena be identified, but the cephalic extent of the tumor must also be
correctly assessed for preoperative planning. Depending on the level of
an IVC thrombus, the surgeon may need to perform a thoracoabdominal
incision instead of an abdominal incision. Intra-atrial thrombus may
require cardiac bypass. Intrahepatic caval thrombus may require open
thrombectomy or, if there is transmural invasion of the caval wall, a
graft placement. Thrombus limited to the renal vein ostia may be
\"milked\" back into the vein without the need to open the vein.
Therefore, accurate assessment of caval thrombus is important.

Dynamic enhanced CT is the most commonly employed method of identifying
caval thrombus. Studies have shown that the technique used influences
the success of CT, particularly with regard to the speed of scanning and
rate of contrast media administration. Multi-detector-row CT shows very
high accuracy rates, achieving equivalence with MRI. Signs suggestive of
renal vein or caval thrombus include filling defects, enlargement of the
vessel, and rim enhancement. With good technique, helical CT achieves
85% to 91% sensitivity routinely. Problems occur with technically
inadequate boluses of contrast media, motion and flow artifact
(especially with foot injections), and renal insufficiency. Venous
anomalies should be sought, specifically the presence of a retroaortic
left renal vein or circumaortic left renal vein, as these have surgical
implications.

MRI is 83% to 100% sensitive for tumor thrombus but routinely achieves
90% to 100% sensitivity with modern equipment and may be slightly more
accurate than CT in assessing the cephalic extent of the thrombus.
Pitfalls of MRI include large tumors compressing the vena cava and
flow-related artifacts, which can be reduced with appropriate saturation
pulses. With bright blood techniques, rapid or turbulent flow can also
lead to artifacts. Intravenous contrast may be helpful in this setting.
The highest sensitivity and specificity in assessing venous involvement
are achieved with gradient echo sequence. Bland thrombus (low signal
intensity) can be distinguished from tumor thrombus, which exhibits
intermediate-signal intensity. However, if a good-quality CT is obtained
at several phases after contrast administration and the vein is clearly
seen, MRI is usually not needed.

Other techniques include US, which is approximately 50% to 75% sensitive
for caval thrombus and can be helpful for quickly identifying the
cephalad extent of a tumor thrombus. US is limited in obese patients and
in the presence of bowel gas, which interferes with the ability to image
the renal vein-IVC junction.

Cavography is approximately 85% to 100% sensitive for detecting caval
thrombus and is equal to MRI in accuracy. However, multidetector,
multiphasic CT or MRI suffices to diagnose caval thrombus, and thus
catheter cavography is rarely needed.

Angiography has proved insensitive for tumor thrombus. Its main roles
are preoperative embolization to reduce blood loss in hypervascular
tumors and for palliation of hematuria in inoperable tumors.

For TxN+ disease (lymph node involvement), CT and MRI are approximately
equal, and both are superior to US. All imaging is suboptimal for N
staging because of the reliance on node size for assessing metastases.
MR lymphography with iron oxide nanoparticles shows promise as a
methodology to identify tumor within lymph nodes regardless of their
size. The agent is not yet available in the United States, however, and
there is no large reported experience with its use in renal cell
carcinoma. From a surgical perspective, the identification of nodes is
less important because the nodes must be sampled at the time of surgery.

CT-guided aspiration biopsies can be performed if desired for
documenting nodal metastases; however; they are rarely needed. Imaging
is important for the preoperative detection of bulky adenopathy, which
might complicate the surgical approach. This is especially true for
laparascopic nephrectomies in which both the vascular anatomy and the
nodal pathology may be poorly visualized. Accurate preoperative
information becomes even more important, especially for centrally
located renal tumors, emphasizing the need for computed tomography
angiography (CTA) or magnetic resonance angiography (MRA) prior to such
a procedure.

The presence of T4M0--1 disease (metastatic disease with contiguous
invasion) is also important to the surgeon. Common sites of contiguous
organ invasion include the liver, diaphragm, psoas muscles, pancreas,
and bowel. Neither CT nor MRI is ideal, because it is impossible at
times to distinguish lack of a fat plane from immediately adjacent but
not invasive tumor or from directly invasive tumor; however, both
techniques perform well, with a sensitivity and specificity \>90%. The
multiplanar capabilities of MRI can be useful in this regard; however,
neither technique always assesses liver or diaphragmatic invasion
correctly. Angiography can also be misleading, since tumors can recruit
vessels from the liver or elsewhere without the tumor actually invading
the organ.

T4M1N+ disease (distant metastases) principally affects the chest, bone,
liver, and brain. Routine chest radiographs are considered necessary,
but the routine use of chest CT is more controversial. For small lesions
(\<3 cm) the risk of metastases is so small as to eliminate the need for
chest CT; however, the risk increases with the size of the primary
tumor, and although universally accepted guidelines do not yet exist
chest CT is justified for larger tumors. When the chest radiograph is
suspicious or positive, chest CT is useful for confirming or excluding
metastases and defining the extent of disease.

In a study of 119 patients undergoing preoperative CT staging, routine
pelvic CT yielded no findings related to the renal cell carcinoma.

Similarly, neither routine bone scans nor bone surveys appear routinely
justified. However, if the patient has an elevated alkaline phosphatase,
bone pain, or an extremely large and aggressive tumor, bone scans may be
helpful. Furthermore, brain MRI does not appear routinely justified, but
it is indicated when neurologic symptoms are present, if the primary
tumor is large, or if other metastatic disease is already present.

Positron emission tomography (PET) does not yet have an established role
in staging renal cancer. Early studies using FDG-PET suggest that it may
be difficult to even detect primary renal cancers against the normal
background of high activity in the kidneys. PET may be helpful for
establishing metastatic disease in lesions detected by CT, MRI, or bone
scan, and it may be used to detect unsuspected metastases in high-risk
patients. Although negative PET results cannot exclude metastatic
disease, a positive PET scan should be considered highly suspicious for
local recurrence or metastatic disease due its high specificity.

**Summary**

Thus, the routine staging of renal cancer should depend on the size of
the primary tumor. For small or incidentally detected tumors (≤3 cm),
multidetector, multiphasic CT of the abdomen with either CT of the chest
or chest radiography is usually sufficient. MRI of the abdomen is a
suitable substitute when the patient cannot undergo contrast-enhanced
CT. If symptoms of bone pain or neurologic symptoms exist, bone scan or
MRI of the brain may be employed.

For larger primary tumors (\>3 cm), multidetector, multiphasic CT of the
abdomen with chest CT is the diagnostic modality of choice. If the
status of the renal veins and inferior vena cava cannot be resolved on
CT, contrast-enhanced multiphasic 3D MR venography (MRV) should be
performed. MRI of the abdomen is a suitable substitute for staging renal
cancer when the patient cannot undergo contrast-enhanced CT.

US may be performed prior to surgery to ascertain the cephalad extent of
a previously identified caval tumor thrombus but cannot be relied upon
to detect small renal vein or IVC thrombus. Cavography is employed only
in unusual circumstances. Prior to any major surgery to remove a locally
advanced primary tumor, brain MRI and bone scan should be performed.
Lesions detected by any modality that are suspicious for metastatic
disease should be either biopsied or examined with an FDG-PET scan.

Although not strictly staging, CTA and MRA should be incorporated into
any staging study of the renal cancer, as the vascular information can
be helpful to surgeons in planning a resection. Catheter angiography can
be performed to embolize large tumors prior to resection.

**Anticipated Exceptions**

In patients with history of adverse reaction to contrast media or renal
insufficiency, MRI and/or US may be preferred to CT. MRI is superior to
US in evaluating lymphadenopathy, determining the organ of origin of the
mass, diagnosing intracaval and renal venous thrombus, and demonstrating
bone metastases.

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

-   CTA, computed tomography angiography

-   FDG-PET, fluorodeoxyglucose positron emission tomography

-   INV, invasive

-   IP, in progress

-   Med, medium

-   Min, minimal

-   MRA, magnetic resonance angiography

-   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 renal cell
carcinoma staging

#### POTENTIAL HARMS

The relative radiation level is high for fluorodeoxyglucose positron
emission tomography (FDG-PET) of the whole body; medium for computed
tomography angiogram (CTA) of the abdomen, CT of the chest, and nuclear
medicine (NUC) bone scan of the whole body; and low for X-ray
radiographic survey of the whole body.

### CONTRAINDICATIONS

#### CONTRAINDICATIONS

In patients with history of adverse reaction to contrast media or renal
insufficiency, MRI and/or US may be preferred to CT.

### 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
radiologists, radiation oncologists, 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

Getting Better\
Living with Illness

#### IOM DOMAIN

Effectiveness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

Curry NC, Francis IR, Baumgarten DA, Bluth EI, Bush WH Jr, Casalino DD,
Israel GM, Jafri SZ, Kawashima A, Papanicolaou N, Remer EM, Sandler CM,
Spring DB, Fulgham P, Expert Panel on Urologic Imaging. Renal cell
carcinoma staging. \[online publication\]. Reston (VA): American College
of Radiology (ACR); 2007. 8 p. \[48 references\]

#### ADAPTATION

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

#### DATE RELEASED

1995 (revised 2007)

#### GUIDELINE DEVELOPER(S)

American College of Radiology - Medical Specialty Society

#### SOURCE(S) OF FUNDING

The 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

*Names of Panel Members*: Nancy S. Curry, MD; Isaac R. Francis, MD2;
Deborah A. Baumgarten, MD; Edward I. Bluth, MD; William H. Bush, Jr.,
MD; David D. Casalino, 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.

It updates a previous published version: Choyke PL, Bluth EI, Bush WH
Jr, Casalino DD, 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. Renal cell
carcinoma staging. \[online publication\]. Reston (VA): American College
of Radiology (ACR); 2005. 5 p. \[40 references\]

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/RenalCellCarcinomaStagingDoc14.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 summary was completed by ECRI on May 6, 2001. The information was
verified by the guideline developer on June 29, 2001. This summary was
updated by ECRI on September 8, 2004. The updated information was
verified by the guideline developer on October 8, 2004. This NGC summary
was updated by ECRI on February 9, 2006. This NGC summary was updated by
ECRI Institute on December 4, 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

#### NGC DISCLAIMER

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Date Modified: 11/3/2008