Question:

Positron emission tomography is useful in evaluating patients with suspected renal cell carcinoma in which of the following settings?
1. Establishing the diagnosis in a patient with a single, solid 3 cm renal mass.
2. Evaluating a small (<0.5 cm) renal mass near the collecting system.
3. Identifying the extent of a renal vein tumor thrombus.
4. Evaluating the renal collecting system for filling defects.
5. Identification of lymph node and bony metastases.





Answer:

The correct answer for the question "Positron emission tomography is useful in evaluating patients with suspected renal cell carcinoma in which of the following settings?" is:

5. Identification of lymph node and bony metastases.



Explanation
a. PET is unlikely to confer additional information that would change the management of a patient with a single solid renal mass.  [The precise role of FDG-PET in the diagnosis and staging of RCC remains somewhat elusive, with the highest utility in detecting visceral, lymph node and bony disease.] 

b. Because radiotracer is excreted in the urine, it is difficult to evaluate small lesions near the collecting system with PET.  [The precise role of FDG-PET in the diagnosis and staging of RCC remains somewhat elusive, with the highest utility in detecting visceral, lymph node and bony disease.]

c. PET is not helpful in determining the extent of renal vein tumor thrombi; MRI is more appropriate for this purpose.  [The precise role of FDG-PET in the diagnosis and staging of RCC remains somewhat elusive, with the highest utility in detecting visceral, lymph node and bony disease.]

d. Radiotracer is excreted in the urine and, therefore, is inappropriate for evaluating the collecting system; a CT intravenous pyelogram or retrograde pyelography would be more appropriate for this purpose.  [The precise role of FDG-PET in the diagnosis and staging of RCC remains somewhat elusive, with the highest utility in detecting visceral, lymph node and bony disease.] 

e. PET is an appropriate study for identifying lymph node and bony metastases.  [The precise role of FDG-PET in the diagnosis and staging of RCC remains somewhat elusive, with the highest utility in detecting visceral, lymph node and bony disease.]



From the manuscript:
Co-existing Sarcoidosis Confounds the Staging of Bilateral Renal Cell Carcinoma
Radiology Case. 2011 Jan; 5(1):18-27


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From the manuscript

Co-existing Sarcoidosis Confounds the Staging of Bilateral Renal Cell Carcinoma

Free full text article: Co-existing Sarcoidosis Confounds the Staging of Bilateral Renal Cell Carcinoma

Abstract
We present a case in which the undiagnosed condition of sarcoidosis complicated the staging of bilateral, subtype-discordant renal cell carcinoma. Initially thought to have metastatic renal cell carcinoma based on computed tomography imaging and referred for immunotherapy, a positron emission tomography/computed tomography scan demonstrated different levels of radiotracer activity in the primary site and the presumed pulmonary metastatic sites. The patient underwent bilateral partial nephrectomies and was ultimately diagnosed with stage T1 bilateral renal cell carcinoma and sarcoidosis. This case highlights the need to consider concurrent medical conditions that can lead to false positive results when evaluating for metastatic disease with imaging studies as well as the importance of evaluating the levels of radiotracer activity between different sites.






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