High-quality computed tomography (CT) scan both prior to and following administration of intravenous contrast remains the radiologic modality for choice to work up a renal mass. Magnetic resonance imaging (MRI) may be useful in the setting of locally advanced disease, venous involvement, renal insufficiency, or allergy to IV contrast. However, due to concerns related to a potential link between nephrogenic systemic fibrosis (NSF) and gadolinium exposure, routine use of MRI is not advocated, and MRI should be reserved for patients who have had a previous allergic reaction to contrast (American Urological Association [AUA], 2009). Color flow Doppler imaging may be useful in detecting renal vein/vena cava involvement. Metastatic evaluation includes CT of the abdomen and pelvis, chest X-ray, and liver function tests. If chest xray is abnormal, then a CT of the chest is warranted. Bone scan should be ordered if there is an elevation of alkaline phosphatase and/or bone pain (Seaman, Goluboff, Ross, & Sawczuk, 1996).
The role of biopsy for localized renal tumor has evolved. Initially, renal biopsy was believed to offer no significant benefit except in patients with metastases in which a diagnosis was needed. However, more recently, the role of renal biopsy has been re-examined. This is supported by the fact that about 20% of clinical Stage 1 renal masses may be benign, and improvements in accuracy and safety of biopsy, related to better CT and MRI-guided techniques, have resulted in a reconsideration of the role of biopsy (Kummerlin et al., 2008; Lane et al., 2007; Lebret et al., 2007; Oda et al., 2001; Pahernik, Ziegler, Roos, Melchior, & Thuroff, 2007; Remzi et al., 2006; Salamanca et al., 2007; Schmidbauer et al., 2008; Somani et al., 2007; Volpe et al., 2007; Zagoria, Gasser, Leyendecker, Bechtold, & Dyer, 2007). In a review of the pathology and radiology databases of a single tertiary referral from 2000 to 2009, Ramsey and colleagues (2010) suggested that renal biopsy is no longer simply for diagnostic dilemmas in patients with renal masses. Older adult patients under consideration for targeted therapies and unfit for cytoreductive nephrectomy have established a role for renal biopsy in confirming the diagnosis prior to treatment (Ramsey et al., 2010).