Stant metastases (17). In addition to stage, the type of tumor cell appears to affect survival. buy viagra online without script Spindle cell and anaplastic tumors carry a worse prognosis than clear or granular cell cancers (16). Treatment decisions hinge on the extent and stage of the tumor. Since the only curative treatment for renal cell carcinoma remains complete surgical excision, the goals of preoperative ct are to delineate the primary tumor, detect and map the extent of venous spread, and diagnose local or distant metastases. buy viagra online The two commonly used staging systems along with their ct findings are outlined in table 2. The major disadvantage of the older and simpler robson classification is that it groups together (in stage iii) a heterogeneous patient population; patients with venous extension alone are generally surgical candidates, whereas those with lymph node metastases have a poorer prognosis and undergo palliative therapy. Thus, despite its complexity, the tnm classification, which defines the anatomic extent of the tumor more precisely, has gained wide acceptance (2). Tumors confined within the renal capsule patients with renal cell carcinoma confined to the kidney (fig 2) have the best prognosis, with 5-year survival rates of 60%–90% after nephrectomy (17). Many such tumors are detected incidentally at cross-sectional imaging performed for unrelated indications. The recent modification of the tnm classification that separates tumors 7 cm or less in diameter (stage t1) from those equal to or greater than 7 cm in diameter (stage t2) reflects the impact of tumor size on survival (2). Perinephric spread of tumor under- and overstaging of perinephric invasion are the most common staging errors at ct (4,18). generic viagra price comparisons The most specific finding of stage t3a disease, the presence of an enhancing nodule in the perinephric space, is highly specific but only 46% sensitive (fig 3) (18). buy generic viagra online Spread of tumoral tissue within the perinephric fat cannot always be reliably diagnosed, and differentiation between stage t2 and t3a tumors is problematic (fig 4). order viagra Perinephric stranding does not reliably indicate tumoral spread and is found in about half of patients with localized t1 and t2 tumors (fig 5). In these patients, perinephric stranding may be caused by edema, vascular engorgement, or previous inflammation. This limitation of ct does have prognostic implications but does not affect case management, since patients with stage t3a disease are candidates for radical nephrectomy or nephron-sparing nephrectomy. taking 40mg of viagra Imaging of the ipsilateral adrenal gland the prevalence of adrenal metastases is low, reported at 4. viagra viagra viagra line 3% in one large series (19). viagra online The risk of adrenal spread is higher among patients with large or. buy viagra youngest age use viagra

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