Introduction

60-year-old patient presented to her GP with haematuria and a persistent cough. Urine and blood samples may have  indicated issues with serum creatinine and glomerular filtration rate (European Association of Urology, 2017). The patient had reduced liver function which led to biologic treatment for tuberculosis being discontinued one year previously. In keeping with recommendations (NHS, 2016),  patient was referred to the urology department from the GP for an ultrasound. This essay considers the contribution of diagnostic imaging to the patient’s management in terms of diagnosis, staging, treatment and followup. 

Diagnosis

-Ultrasound

DoH targets (2011) -patients with suspected renal malignancy to be diagnosed within 2 weeks

-Ultrasound is quick, relatively cheap and accessible

– differentiates between solid and cystic masses, indicates size and vascularity (Rossi et al., 2018). Authors are multi-disciplinary UK professionals, making source particularly relevant to this patient’s care. However, some citations are old therefore some information may not be up to date. However, other sources have supported the accuracy of ultrasound, particularly with contrast enhancement, to characterize kidney lesions

sens: 88%, spec: 80%- Wang et al., 2014; sens: 96%, spec: 50%- Chang et al., 2017.

The patient’s examination identified a 6cm kidney lesion.

Staging

-CT

sensitivity: 60%, spec: 73%, PPV: 43%, NPV: 84%- Millet et al. (2011) 

The patient underwent a CT scan of the chest, abdomen and pelvis with contrast. “gold standard choice” (Rossi et al., 2018).This is in accordance with recommendations of a contrast-enhanced CT scan of the abdomen and thorax for staging following the identification of a suspicious lesion. In addition, MR imaging or a bone scan is suggested (NHS England, 2016).

-MRI

Despite MRI being available, patient did not have an MRI scan potentially due to the waiting time or contraindications.

-Nuclear medicine bone scan

This demonstrated multiple areas of increased uptake.  Following these scans,  patient was discussed at MDT in accordance with NHS guidance (2016). The case is complicated by known latent tuberculosis infection. Since myobacteria is repressed by the patient’s immune system, undergoing immunocompromising cancer treatment could have reactivate the TB (Nachiappan et al., 2017).  Thus team were keen to ascertain whether the lesion was infectious or malignant as this greatly affected the treatment plan.

-Ultrasound-guided vs CT biopsy

Treatment (NICE, 2019)

Interventional procedure– percutaneous or laparoscopic nephrectomy, radiofrequency ablation or cryotherapy 

Drugs– Cabozantinib, Tivozanib, Pazopanib, Sunitinib 

 

Follow up

Diagnostic imaging to assess the success of treatment

How well managed the tuberculosis infection is 

CT

FDG-PET/CT sens: 46.6%, spec: 66.6% –Olzuker et al. (2011)

References 

Capitanio, U. and Montorsi, F. (2016) Renal Cancer. The Lancet [online]. 387(10021), pp. 894-906.

Department of Health and Social Care (2011) Improving outcomes: a strategy for cancer [online]. London: Department of Health. (15108). Available from: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/213785/dh_123394.pdf [Accessed 1 March 2019].

European Association of Urology (2017) EAU Guidelines on Renal Cell Carcinoma: The 2017 Update [online]. Available from: uroweb.org/wp-content/uploads/10-Renal-Cell-Carcinoma_2017_web.pdf [Accessed 28 February 2019]. 

Millet,  I., Doyon, F., Hoa, D., Thuret, R., Merigeaud, S., Serre, I. and Taourel, P. (2011) Characterization of Small Solid Renal Lesions: Can Benign and Malignant Tumors Be Differentiated With CT? AJR [online]. 197(4), pp. 887-896.  [Accessed 1 March 2019].

National Health Service England (2016) Guidelines for the Management of Renal Cancer (online). Available from: https://www.england.nhs.uk/mids-east/wp-content/uploads/sites/7/2018/05/guidelines-for-the-management-of-renal-cancer.pdf [Accessed 25 February 2019]. 

Nachiappan, A., Rahbar, K., Shi, X., Guy, E., Barbosa, E., Shroff, G., Ocazionez, D., Schlesinger, A., Katz, S. and Hammer, M. (2017) Pulmonary Tuberculosis: Role of Radiology in Diagnosis and Management. RSNA (online). 37 (1), pp. 52-72. [Accessed 27 February 2019]. 

National Institute for Health and Care Excellence (2015) Suspected cancer: recognition and referral [online]. London: Department of Health. (NG12). Available from: https://www.nice.org.uk/guidance/ng12/evidence/full-guideline-pdf-2676000277 [Accessed 25 February 2019].  

National Institute for Health and Care Excellence (2019) Renal Cancer Overview Flowchart [online]. London: Department of Health. Available from: https://pathways.nice.org.uk/pathways/renal-cancer#content=view-node%3Anodes-procedures-for-treating-renal-cancer [Accessed 25 February 2019].

Ozulker T, Ozulker F, Ozbek E, (2011) A prospective diagnostic accuracy study of F-18 fluorodeoxyglucose-positron emission tomography/computed tomography in the evaluation of indeterminate renal masses. Nuclear Medicine Communications [online]. 32 (no issue number), pp.265–272. 

Rossi, S., Prezzi, D., Kelly-Morland, C. and Goh, V. (2018) Imaging for the diagnosis and response assessment of renal tumours. World Journal of Urology [online]. 36(12), pp.1927-1944.  

Wang, C., Yu, C., Yang, F., Yang, G. (2014) Diagnostic accuracy of contrast-enhanced ultrasound for renal cell carcinoma: a meta-analysis. Tumor Biology [online]. 35(7), pp. 6343–6350.  

Wang, H., Ding, H., Chen, J., Chao, C., Meta-analysis of the diagnostic performance of [18F]FDG-PET and PET/CT in renal cell carcinoma. Cancer Imaging [online]. 12(3), pp. 464-474.