Locally advanced and metastatic renal cell carcinoma (RCC) present a specific set of challenges to the radiologist. The detection of metastatic disease is confounded by the ability of RCC to metastasize to virtually any part of the human body long after surgical resection of the primary tumor. This includes sites not commonly included in routine surveillance, which come to light after the patient becomes symptomatic. In the assessment of treatment response, the phenomenon of tumor heterogeneity, where clone selection through systemic therapy drives the growth of potentially more aggressive phenotypes, can result in oligoprogression despite overall disease control. Finally, advances in therapy have resulted in the development of immuno-oncologic agents that may result in changes that are not adequately evaluated with conventional size-based response criteria and may even be misinterpreted as progression. This article reviews the common challenges a radiologist may encounter in the evaluation of patients with locally advanced and metastatic RCC. ©RSNA, 2019.

Radiographics : a review publication of the Radiological Society of North America, Inc. 2019 Jun 14 [Epub ahead of print]

Alberto Diaz de Leon, Ali Pirasteh, Daniel N Costa, Payal Kapur, Hans Hammers, James Brugarolas, Ivan Pedrosa

From the Department of Radiology (A.D.d.L., A.P., D.N.C., I.P.), Advanced Imaging Research Center (D.N.C., I.P.), Department of Pathology (P.K.), Department of Urology (P.K.), Kidney Cancer Program-Simmons Comprehensive Cancer Center (P.K., H.H., J.B., I.P.), and Department of Internal Medicine (H.H., J.B.), UT Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390.