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  • Guideline Summary
  • NGC:010165
  • 1996 (revised 2013)

ACR Appropriateness Criteria® post-treatment follow-up of renal cell carcinoma.

Casalino DD, Remer EM, Bishoff JT, Coursey CA, Dighe M, Harvin HJ, Heilbrun ME, Majd M, Nikolaidis P, Preminger GM, Raman SS, Sheth S, Vikram R, Weinfeld RM, Expert Panel on Urologic Imaging. ACR Appropriateness Criteria® post-treatment follow-up of renal cell carcinoma. [online publication]. Reston (VA): American College of Radiology (ACR); 2013. 9 p. [63 references]

View the original guideline documentation External Web Site Policy

This is the current release of the guideline.

This guideline updates a previous version: Casalino DD, Francis IR, Arellano RS, Baumgarten DA, Curry NS, Dighe M, Fulgham P, Israel GM, Leyendecker JR, Papanicolaou N, Prasad S, Ramchandani P, Remer EM, Sheth S, Expert Panel on Urologic Imaging. ACR Appropriateness Criteria® follow-up of renal cell carcinoma. [online publication]. Reston (VA): American College of Radiology (ACR); 2009. 6 p.

UMLS Concepts (what is this?)

Major Recommendations

ACR Appropriateness Criteria®

Clinical Condition: Post-treatment Follow-up of Renal Cell Carcinoma

Variant 1: Asymptomatic patient; no known metastases.

Radiologic Procedure Rating Comments RRL*
X-ray chest 8 This procedure is not necessary if a chest CT is performed. radioactive
CT abdomen and pelvis with contrast 8 This procedure is particularly appropriate if the primary disease was high stage and/or high grade. CT and MRI are alternative examinations. radioactive radioactive radioactive radioactive
MRI abdomen and pelvis without and with contrast 8 This procedure is equivalent to CT. See statement regarding contrast in text below under "Anticipated Exceptions." O
CT abdomen and pelvis without and with contrast 6 This procedure is particularly appropriate if the patient is postablation or has a hereditary renal cancer syndrome. The noncontrast scan is not needed in the pelvis. radioactive radioactive radioactive radioactive
CT chest with contrast 6 This procedure is particularly appropriate if patients are considered at high risk for metastatic disease. radioactive radioactive radioactive
CT chest without contrast 5 This procedure is particularly appropriate if patients are considered at high risk for metastatic disease. radioactive radioactive radioactive
MRI abdomen and pelvis without contrast 5   O
CT abdomen and pelvis without contrast 4   radioactive radioactive radioactive radioactive
FDG-PET/CT whole body 4 This procedure may have a role when CT and bone scan findings are equivocal. radioactive radioactive radioactive radioactive
US kidney retroperitoneal 3   O
CT chest without and with contrast 2   radioactive radioactive radioactive
X-ray intravenous urography 2   radioactive radioactive radioactive
Tc-99m bone scan whole body 2   radioactive radioactive radioactive
MRI head without and with contrast 1   O
MRI head without contrast 1   O
X-ray abdomen 1   radioactive radioactive
CT head without and with contrast 1   radioactive radioactive radioactive
CT head without contrast 1   radioactive radioactive radioactive
CT head with contrast 1   radioactive radioactive radioactive
X-ray radiographic survey whole body 1   radioactive radioactive radioactive
Rating Scale: 1,2,3 Usually not appropriate; 4,5,6 May be appropriate; 7,8,9 Usually appropriate *Relative Radiation Level

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

Summary of Literature Review

Introduction/Background

In this document the authors address the appropriate imaging examinations for asymptomatic patients who have been treated for renal cell carcinoma (RCC) by radical nephrectomy or nephron-sparing surgery. They do not deal with patients who are undergoing systemic therapy for known recurrent RCC; patients in whom specific symptoms, signs, or laboratory studies suggest recurrent malignancy at a specific site; or patients for whom surgery is known to have left a residual tumor; they do not address the imaging of nononcologic complications of surgery.

Follow-up is important for patients who have had radical or partial nephrectomy for RCC. Although patients may have been initially considered cured, local or distant metastatic recurrences may develop in 20% to 50% of cases and require further management. Solitary metastasis may occasionally be treated by resection. Until recently, systemic treatment for metastatic RCC was limited primarily to cytokine therapy, including interferon alfa and interleukin-2; however, the use of these agents has been limited by their toxicity as well as generally poor response rates. Targeted therapy using tyrosine kinase inhibitors is now available and has shown significant antitumor effects and meaningful clinical benefit.

Common anatomic locations of recurrences dictate the choice of imaging modalities. The tumor may recur in the resection site, especially if the primary tumor is large, high grade, or has a higher tumor (T) stage. The incidence of tumor recurrence in the resection site is similar to or only slightly higher in patients who have had partial nephrectomy, compared with those who have had radical nephrectomy. More commonly, however, 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 the higher stage of the primary tumor. In decreasing order of frequency, metastases most commonly appear in the lung (with or without mediastinal or hilar nodes), bone, 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 RCC are worth considering. Most lung metastases are (at least early in their history) asymptomatic. Metastases in thoracic nodes usually indicate a short survival time. 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 (i.e., the areas likely to be included in chest and abdomen examination). Most recurrences appear within 2 to 3 years after the initial resection but may not occur until decades later. Tumor recurrences tend to occur earlier in patients who have higher T stages; tumors that appear after a long interval seem to be associated with a better prognosis. Therefore, one can argue either that routine follow-up should be limited to only a few years or that halting follow-up after a brief period can deprive those patients, who might benefit most from treating recurrences, of an early diagnosis.

Several stage-based surveillance protocols for RCC after radical or partial nephrectomy have been proposed. They are summarized as follows:

  • For T1 tumors: Because the risk of metastasis 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 annually until year 5. Others have suggested that no imaging be performed if the tumor is <2.5 cm. Most protocols do not recommend surveillance with abdominal computed tomography (CT) for patients who have T1 tumors.
  • For T2 primary tumors: Most protocols recommend that history, physical examination, laboratory tests, and a chest radiograph be obtained every 6 months or annually for 3 years and then annually until year 5. Protocols vary widely regarding the use of abdominal CT. Some do not recommend CT at all, while others recommend CT at years 2 and 5. Still others recommend a CT annually or every other year for 3 years after surgery and 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 the first few years and annually thereafter. The vast majority of protocols recommend abdominal CT, with most recommending CT imaging every 3 to 6 months for 3 years after surgery and annually or every other year thereafter.

It is likely that incorporating molecular biomarkers, such as IMP-3 and p53, and microvascular invasion into prognostic models will improve their accuracy and allow for more individualized postoperative surveillance protocols in the future.

Preliminary studies suggest that fluorine-18-2-fluoro-2-deoxy-D-glucose positron emission tomography/CT (FDG-PET/CT) can be used to evaluate tumor recurrence in patients who have undergone surgery for RCC. FDG-PET-CT was shown to be comparable to conventional imaging methods (chest radiography or chest CT, abdominal CT, and bone scan) in the postoperative surveillance of patients who have a higher risk for RCC (T2, T3, and T4 tumors).

Pulmonary Metastases

Because 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 radiograph and chest CT. If the chest radiograph is positive, CT almost inevitably follows in order to plan for and monitor further therapy. The chest radiograph 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 if there is just one lesion, which might be amenable to resection, than if there are several) and is probably more sensitive than chest radiograph in detecting metastases in the thoracic spine, ribs, shoulder bones, and nodes. CT is also more likely to display small granulomas that can masquerade as metastases and require further workup. Although the extra yield from chest CT compared to chest radiography is probably too small to warrant its use in routine surveillance, some physicians prefer to use chest CT, especially for patients who have T3 or T4 primary tumors or nodal disease. Mediastinal and hilar lymph node metastases are an independent prognostic factor for decreased survival after pulmonary metastasectomy in patients who have RCC, and systematic lymphadenectomy can potentially prolong survival. A few studies have shown FDG-PET to be highly specific in detecting chest metastases, but the sensitivity is limited. With advancements in MRI, whole-body MRI is feasible in the follow-up of patients who have RCC, but the accuracy of MRI for detecting pulmonary metastases is inferior to that of CT (71.9% versus 88.5%, P<0.001).

Abdominal Recurrences

Abdominal recurrences may occur at the surgical site or metastasize to the liver, lymph nodes, adrenal glands, bones, etc. Although a few studies have argued against routine imaging of the abdomen after resection of low-stage tumors (T1 and certain T2 tumors), abdominal surveillance is commonly performed with a contrast-enhanced CT of the abdomen and pelvis. Although 2 retrospective studies concluded that CT imaging of the pelvis has limited value for RCC staging, the value of imaging the pelvis during follow-up after RCC treatment has not been determined. CT is sensitive in detecting metastases in the resection site, contralateral kidney, adrenal glands, liver, and bones included in the examination. In a recent study, researchers suggested that an arterial phase of imaging is complementary to the portal venous phase in detecting RCC metastases to the liver and pancreas. In their study of 100 patients, 9 patients had metastases detected only in the arterial phase, and management was changed for 2 patients. Use of MRI, preferably with contrast, should be considered in place of CT for younger patients, who will likely require multiple scans, and for patients with a history of allergy to iodinated contrast.

FDG-PET can be a useful adjunct to CT or MRI, particularly when a local recurrence is suspected in a renal fossa that could have postoperative and postradiation changes. Performing separate nuclear medicine liver-spleen, bone, and renal scans is not practical. Ultrasound (US) has demonstrated some success in detecting intra-abdominal recurrences, but it has never been shown to be as sensitive as CT. Also, US is likely to be less sensitive in detecting small, resection-bed metastases, especially if the nephrectomy was performed on the left side and if the bowel occupies the surgical site. Radiography, angiography, and intravenous urography do not have a role in postoperative surveillance.

Osseous Metastases

Surveillance for metastases to the skeleton might be conducted using serial radionuclide bone scans or not at all, unless the patient develops specific symptoms, usually local pain or abnormal alkaline phosphatase levels. Most authors do not suggest routine bone scanning to search for metastases without symptoms, because the vast majority of bone metastases are symptomatic and incurable. When a bone metastasis is suspected, a bone scan is most often performed to survey the entire skeleton. If the bone scan is positive, a radiograph might be considered to rule out impending fracture. Whole-body MRI has a specificity similar to that of a bone scan (94% and 97%, respectively) and sensitivity (94%) superior to the bone scan (62%) for detecting bone metastases. Identification of bone metastases can help facilitate treatment for pain relief and prevent pathologic fracture.

Relatively little has been written regarding the use of radiography or scintigraphy to monitor patients in the postoperative phase. FDG-PET can be used when CT or bone scan findings are equivocal. FDG-PET can reveal bone metastases that are not detected by a bone scan; however, false-negative results have also been reported.

Brain Metastases

Surveillance protocols for RCC have not supported routine imaging of the brain to search for metastases in asymptomatic patients.

Follow-up of Renal Cell Carcinoma after Ablative Therapies

As an alternative to partial nephrectomy, energy-ablative therapies, such as cryoablation and radiofrequency ablation (RFA), are being used to treat small RCCs. These therapies have been shown to be effective and safe. Cryoablation and RFA have similar efficacies for treating small renal masses, and the approach—percutaneous versus laparoscopic—does not seem to change oncologic efficacy. Recent studies with follow-up data exceeding 5 years strongly support the long-term oncologic efficacy of RFA for RCCs under 4 cm. Postablative CT and MRI play an important role in the evaluation of the ablation zone, surveillance for a residual or recurrent tumor, identification of procedure-related complications, and detection of new RCCs.

A multi-institutional study found that 63 of 616 patients (10.2%) had residual or recurrent tumors after primary ablation. A residual tumor was defined as enhancement in the vicinity of the treated tumor on the first imaging study after the ablative procedure, and a 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 2 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 1 after ablative therapy, with studies being performed at months 1, 3, 6 (optional), and 12. The CT or MRI should be a dedicated renal examination 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 every 6 to 12 months after year 1. More recently it has been suggested that patients be followed for at least 5 years with initial CT or MRI at 1 to 3 months postablation, then every 6 months for 3 intervals, and annually thereafter. Periodic chest radiography or CT was also recommended for thoracic surveillance. Others have suggested follow-up imaging at 4 to 6 weeks, 6 months, and annually thereafter. One study reported that a history of contralateral radical nephrectomy for RCC was an independent predictor of disease recurrence after cryoablation and that 1 patient who had preceding contralateral nephrectomy for RCC developed a duodenal metastasis 90 months after cryoablation.

Although US contrast agents have not yet been approved for clinical applications outside of cardiology in the United States, researchers from Vimercate General Hospital in Milan, Italy, showed that contrast-enhanced US, using a sulfur hexafluoride-filled microbubble contrast agent, was effective in patients following RFA. There was concordance between the results of contrast-enhanced US and contrast-enhanced CT or MRI findings for 27 of 28 treated tumors. Contrast-enhanced US missed only 1 of 7 cases of local tumor progression. Concordant results of the absence of tumor recurrence were noted for the remaining 21 tumors.

Summary

  • Tumor recurrences, whether metastatic or local, are common after resection of localized RCC.
  • The intensity and length of follow-up in patients who have RCC largely depends the stage of the primary tumor.
  • The follow-up generally includes a history and physical examination, complete blood count, liver function tests, and chest radiography.
  • Although there is no clear consensus regarding the timing of abdominal CT in routine surveillance, CT is generally included in the follow-up evaluation of patients after the resection of T2–T4 primary tumors.
  • The literature does not support the routine use of bone scans or brain imaging for asymptomatic patients.
  • FDG-PET appears to be a useful adjunct to conventional imaging.

Anticipated Exceptions

Nephrogenic systemic fibrosis (NSF) is a disorder with a scleroderma-like presentation and a spectrum of manifestations that can range from limited clinical sequelae to fatality. It appears to be related to both underlying severe renal dysfunction and the administration of gadolinium-based contrast agents. It has occurred primarily in patients on dialysis, rarely in patients with very limited glomerular filtration rate (GFR) (i.e., <30 mL/min/1.73 m2), and almost never in other patients. There is growing literature regarding NSF. Although some controversy and lack of clarity remain, there is a consensus that it is advisable to avoid all gadolinium-based contrast agents in dialysis-dependent patients unless the possible benefits clearly outweigh the risk, and to limit the type and amount in patients with estimated GFR rates <30 mL/min/1.73 m2. For more information, please see the American College of Radiology (ACR) Manual on Contrast Media (see the "Availability of Companion Documents" field).

Abbreviations

  • CT, computed tomography
  • FDG-PET, fluorine-18-2-fluoro-2-deoxy-D-glucose positron emission tomography
  • MRI, magnetic resonance imaging
  • Tc, technetium
  • US, ultrasound

Relative Radiation Level Designations

Relative Radiation Level* Adult Effective Dose Estimate Range Pediatric Effective Dose Estimate Range
O 0 mSv 0 mSv
radioactive <0.1 mSv <0.03 mSv
radioactive radioactive 0.1-1 mSv 0.03-0.3 mSv
radioactive radioactive radioactive 1-10 mSv 0.3-3 mSv
radioactive radioactive radioactive radioactive 10-30 mSv 3-10 mSv
radioactive radioactive radioactive radioactive radioactive 30-100 mSv 10-30 mSv
*RRL assignments for some of the examinations cannot be made, because the actual patient doses in these procedures vary as a function of a number of factors (e.g., region of the body exposed to ionizing radiation, the imaging guidance that is used). The RRLs for these examinations are designated as "Varies."

Clinical Algorithm(s)

Algorithms were not developed from criteria guidelines.

Disease/Condition(s)

Renal cell carcinoma

Guideline Category

Evaluation

Clinical Specialty

Nephrology

Nuclear Medicine

Oncology

Pathology

Pulmonary Medicine

Radiation Oncology

Radiology

Surgery

Intended Users

Allied Health Personnel

Health Plans

Hospitals

Managed Care Organizations

Physician Assistants

Physicians

Utilization Management

Guideline Objective(s)

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

Target Population

Asymptomatic patients who have been treated for renal cell carcinoma

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

Interventions and Practices Considered

  1. X-ray
    • Chest
    • Intravenous urography
    • Abdomen
    • Radiographic survey whole body
  2. Computed tomography (CT)
    • Abdomen and pelvis with contrast
    • Abdomen and pelvis without contrast
    • Abdomen and pelvis without and with contrast
    • Chest with contrast
    • Chest without contract
    • Chest without and with contrast
    • Head without contrast
    • Head with contrast
    • Head without and with contrast
  3. Magnetic resonance imaging (MRI)
    • Abdomen and pelvis without and with contrast
    • Abdomen and pelvis without contrast
    • Head without and with contrast
    • Head without contrast
  4. Fluorine-18-2-fluoro-2-deoxy-D-glucose positron emission tomography (FDG-PET) whole body
  5. Ultrasound (US) kidney, retroperitoneal
  6. Technetium (Tc)-99m bone scan whole body

Major Outcomes Considered

  • Utility of radiologic procedures in follow-up evaluation of patients with renal cell carcinoma
  • Tumor recurrence
  • Survival time

Methods Used to Collect/Select the Evidence

Searches of Electronic Databases

Description of Methods Used to Collect/Select the Evidence

Literature Search Procedure

Staff will search in PubMed only for peer reviewed medical literature for routine searches. Any article or guideline may be used by the author in the narrative but those materials may have been identified outside of the routine literature search process.

The Medline literature search is based on keywords provided by the topic author. The two general classes of keywords are those related to the condition (e.g., ankle pain, fever) and those that describe the diagnostic or therapeutic intervention of interest (e.g., mammography, MRI).

The search terms and parameters are manipulated to produce the most relevant, current evidence to address the American College of Radiology Appropriateness Criteria (ACR AC) topic being reviewed or developed. Combining the clinical conditions and diagnostic modalities or therapeutic procedures narrows the search to be relevant to the topic. Exploding the term "diagnostic imaging" captures relevant results for diagnostic topics.

The following criteria/limits are used in the searches.

  1. Articles that have abstracts available and are concerned with humans.
  2. Restrict the search to the year prior to the last topic update or in some cases the author of the topic may specify which year range to use in the search. For new topics, the year range is restricted to the last 10 years unless the topic author provides other instructions.
  3. May restrict the search to Adults only or Pediatrics only.
  4. Articles consisting of only summaries or case reports are often excluded from final results.

The search strategy may be revised to improve the output as needed.

Number of Source Documents

The total number of source documents identified as the result of the literature search is not known.

Methods Used to Assess the Quality and Strength of the Evidence

Weighting According to a Rating Scheme (Scheme Given)

Rating Scheme for the Strength of the Evidence

Strength of Evidence Key

Category 1 - The conclusions of the study are valid and strongly supported by study design, analysis, and results.

Category 2 - The conclusions of the study are likely valid, but study design does not permit certainty.

Category 3 - The conclusions of the study may be valid, but the evidence supporting the conclusions is inconclusive or equivocal.

Category 4 - The conclusions of the study may not be valid because the evidence may not be reliable given the study design or analysis.

Methods Used to Analyze the Evidence

Systematic Review with Evidence Tables

Description of the Methods Used to Analyze the Evidence

The topic author drafts or revises the narrative text summarizing the evidence found in the literature. American College of Radiology (ACR) staff draft an evidence table based on the analysis of the selected literature. These tables rate the strength of the evidence (study quality) for each article included in the narrative text.

The expert panel reviews the narrative text, evidence table, and the supporting literature for each of the topic-variant combinations and assigns an appropriateness rating for each procedure listed in the table. Each individual panel member assigns a rating based on his/her interpretation of the available evidence.

More information about the evidence table development process can be found in the ACR Appropriateness Criteria® Evidence Table Development document (see the "Availability of Companion Documents" field).

Methods Used to Formulate the Recommendations

Expert Consensus (Delphi)

Description of Methods Used to Formulate the Recommendations

Rating Appropriateness

The appropriateness ratings for each of the procedures included in the Appropriateness Criteria topics are determined using a modified Delphi methodology. A series of surveys are conducted to elicit each panelist's expert interpretation of the evidence, based on the available data, regarding the appropriateness of an imaging or therapeutic procedure for a specific clinical scenario. American College of Radiology (ACR) staff distribute surveys to the panelists along with the evidence table and narrative. Each panelist interprets the available evidence and rates each procedure. The surveys are completed by panelists without consulting other panelists. The appropriateness rating scale is an ordinal scale that uses integers from 1 to 9 grouped into three categories: 1, 2, or 3 are in the category "usually not appropriate"; 4, 5, or 6 are in the category "may be appropriate"; and 7, 8, or 9 are in the category "usually appropriate." Each panel member assigns one rating for each procedure for a clinical scenario. The ratings assigned by each panel member are presented in a table displaying the frequency distribution of the ratings without identifying which members provided any particular rating.

If consensus is reached, the median rating is assigned as the panel's final recommendation/rating. Consensus is defined as eighty percent (80%) agreement within a rating category. A maximum of three rounds may be conducted to reach consensus. Consensus among the panel members must be achieved to determine the final rating for each procedure.

If consensus is not reached, the panel is convened by conference call. The strengths and weaknesses of each imaging procedure that has not reached consensus are discussed and a final rating is proposed. If the panelists on the call agree, the rating is proposed as the panel's consensus. The document is circulated to all the panelists to make the final determination. If consensus cannot be reached on the call or when the document is circulated, "No consensus" appears in the rating column and the reasons for this decision are added to the comment sections.

This modified Delphi method enables each panelist to express individual interpretations of the evidence and his or her expert opinion without excessive influence from fellow panelists in a simple, standardized and economical process. A more detailed explanation of the complete process can be found in additional methodology documents found on the ACR Web site External Web Site Policy (see also the "Availability of Companion Documents" field).

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.

Type of Evidence Supporting the Recommendations

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

Potential Benefits

Selection of appropriate radiologic imaging procedures for post-treatment follow-up in patients with renal cell carcinoma

Potential Harms

Fluorine-18-2-fluoro-2-deoxy-D-glucose positron emission tomography (FDG-PET) can reveal bone metastases that are not detected by a bone scan; however, false-negative results have also been reported.

Gadolinium-based Contrast Agents

Nephrogenic systemic fibrosis (NSF) is a disorder with a scleroderma-like presentation and a spectrum of manifestations that can range from limited clinical sequelae to fatality. It appears to be related to both underlying severe renal dysfunction and the administration of gadolinium-based contrast agents. It has occurred primarily in patients on dialysis, rarely in patients with very limited glomerular filtration rate (GFR) (i.e., <30 mL/min/1.73 m2), and almost never in other patients. Although some controversy and lack of clarity remain, there is a consensus that it is advisable to avoid all gadolinium-based contrast agents in dialysis-dependent patients unless the possible benefits clearly outweigh the risk, and to limit the type and amount in patients with estimated GFR rates <30 mL/min/1.73 m2. For more information, please see the American College of Radiology (ACR) Manual on Contrast Media (see the "Availability of Companion Documents" field).

Relative Radiation Level (RRL)

Potential adverse health effects associated with radiation exposure are an important factor to consider when selecting the appropriate imaging procedure. Because there is a wide range of radiation exposures associated with different diagnostic procedures, a relative radiation level indication has been included for each imaging examination. The RRLs are based on effective dose, which is a radiation dose quantity that is used to estimate population total radiation risk associated with an imaging procedure. Patients in the pediatric age group are at inherently higher risk from exposure, both because of organ sensitivity and longer life expectancy (relevant to the long latency that appears to accompany radiation exposure). For these reasons, the RRL dose estimate ranges for pediatric examinations are lower as compared to those specified for adults. Additional information regarding radiation dose assessment for imaging examinations can be found in the ACR Appropriateness Criteria® Radiation Dose Assessment Introduction document (see the "Availability of Companion Documents" field).

Qualifying Statements

The 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 examinations 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.

Description of Implementation Strategy

An implementation strategy was not provided.

IOM Care Need

Living with Illness

IOM Domain

Effectiveness

Bibliographic Source(s)

Casalino DD, Remer EM, Bishoff JT, Coursey CA, Dighe M, Harvin HJ, Heilbrun ME, Majd M, Nikolaidis P, Preminger GM, Raman SS, Sheth S, Vikram R, Weinfeld RM, Expert Panel on Urologic Imaging. ACR Appropriateness Criteria® post-treatment follow-up of renal cell carcinoma. [online publication]. Reston (VA): American College of Radiology (ACR); 2013. 9 p. [63 references]

Adaptation

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

Date Released

1996 (revised 2013)

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

Panel Members: David D. Casalino, MD (Principal Author and Panel Vice-chair); Erick M. Remer, MD (Panel Chair); Jay T. Bishoff, MD; Courtney A. Coursey, MD; Manjiri Dighe, MD; Howard J. Harvin, MD; Marta E. Heilbrun, MD; Massoud Majd, MD; Paul Nikolaidis, MD; Glenn M. Preminger, MD; Steven S. Raman, MD; Sheila Sheth, MD; Raghunandan Vikram, MD; Robert M. Weinfeld, 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, Francis IR, Arellano RS, Baumgarten DA, Curry NS, Dighe M, Fulgham P, Israel GM, Leyendecker JR, Papanicolaou N, Prasad S, Ramchandani P, Remer EM, Sheth S, Expert Panel on Urologic Imaging. ACR Appropriateness Criteria® follow-up of renal cell carcinoma. [online publication]. Reston (VA): American College of Radiology (ACR); 2009. 6 p.

Guideline Availability

Availability of Companion Documents

The following are available:

  • ACR Appropriateness Criteria®. Overview. Reston (VA): American College of Radiology; 2013 Nov. 3 p. Available from the American College of Radiology (ACR) Web site External Web Site Policy.
  • ACR Appropriateness Criteria®. Literature search process. Reston (VA): American College of Radiology; 2013 Apr. 1 p. Available from the ACR Web site External Web Site Policy.
  • ACR Appropriateness Criteria®. Evidence table development. Reston (VA): American College of Radiology; 2015 Nov. 5 p. Available from the ACR Web site External Web Site Policy.
  • ACR Appropriateness Criteria®. Radiation dose assessment introduction. Reston (VA): American College of Radiology; 2013 Nov. 3 p. Available from the ACR Web site External Web Site Policy.
  • ACR Appropriateness Criteria®. Manual on contrast media. Reston (VA): American College of Radiology; 90 p. Available from the ACR Web site External Web Site Policy.
  • ACR Appropriateness Criteria®. Procedure information. Reston (VA): American College of Radiology; 2013 Apr. 1 p. Available from the ACR Web site External Web Site Policy.
  • ACR Appropriateness Criteria® post-treatment follow-up of renal cell cancer. Evidence table. Reston (VA): American College of Radiology; 2013. 23 p. Available from the ACR Web site External Web Site Policy.

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. This NGC summary was updated by ECRI Institute on June 3, 2010. This summary was updated by ECRI Institute on January 13, 2011 following the U.S. Food and Drug Administration (FDA) advisory on gadolinium-based contrast agents. This NGC summary was updated by ECRI Institute on March 7, 2014.

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 External Web Site Policy.

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All guidelines summarized by NGC and hosted on our site are produced under the auspices of medical specialty societies, relevant professional associations, public or private organizations, other government agencies, health care organizations or plans, and similar entities.

Guidelines represented on the NGC Web site are submitted by guideline developers, and are screened solely to determine that they meet the NGC Inclusion Criteria.

NGC, AHRQ, and its contractor ECRI Institute make no warranties concerning the content or clinical efficacy or effectiveness of the clinical practice guidelines and related materials represented on this site. Moreover, the views and opinions of developers or authors of guidelines represented on this site do not necessarily state or reflect those of NGC, AHRQ, or its contractor ECRI Institute, and inclusion or hosting of guidelines in NGC may not be used for advertising or commercial endorsement purposes.

Readers with questions regarding guideline content are directed to contact the guideline developer.