G e n i t o u r i n a r y I m a g i n g • B e s t P r a c t i c e s / R ev i ew

Kang et al.
Solid Renal Masses

Genitourinary Imaging
Best Practices/Review
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FOCUS ON:

Solid Renal Masses: What the

Numbers Tell Us
Stella K. Kang1 OBJECTIVE. Solid renal masses are most often incidentally detected at imaging as small
William C. Huang2 (≤ 4 cm) localized lesions. These lesions comprise a wide spectrum of benign and malignant
Pari V. Pandharipande 3 histologic subtypes, but are largely treated with surgical resection given the limited ability of
Hersh Chandarana1 imaging to differentiate among them with consistency and high accuracy. Numerous studies
have thus examined the ability of CT and MRI techniques to separate benign lesions from
Kang SK, Huang WC, Pandharipande PV, malignancies and to predict renal cancer histologic grade and subtype. This article synthe-
Chandarana H sizes the evidence regarding renal mass characterization at CT and MRI, provides diagnos-
tic algorithms for evidence-based practice, and highlights areas of further research needed to
drive imaging-based management of renal masses.
CONCLUSION. Despite extensive study of morphologic and quantitative criteria at
conventional imaging, no CT or MRI techniques can reliably distinguish solid benign tumors,
such as oncocytoma and lipid-poor angiomyolipoma, from malignant renal tumors. Larger studies
are required to validate recently developed techniques, such as diffusion-weighted imaging.
Evidence-based practice includes MRI to assess renal lesions in situations where CT is limited
and to help guide management in patients who are considered borderline surgical candidates.

I
n this article, we synthesize the without severe comorbidities, the patient was
evidence regarding renal mass taking medications for diabetes and hyperten-
Keywords: angiomyolipoma, diffusion-weighted imaging,
oncocytoma, renal cell carcinoma, renal mass characterization at CT and MRI, sion, and also had a slightly elevated creati-
provide diagnostic algorithms nine level. The emergency department physi-
DOI:10.2214/AJR.14.12502 for evidence-based practice, and highlight cian recommended that the patient schedule
areas of further research needed to drive im- a follow-up appointment with a urologist and
Received January 2, 2014; accepted January 13, 2014.
aging-based management of renal masses. undergo CT of the abdomen and pelvis for re-
S. K. Kang is funded in part by the Association of nal mass evaluation. Several weeks later, the
University Radiologists GE Radiology Research Clinical Vignette patient arrived at the urologist’s office after
Academic Fellowship. P. V. Pandharipande has received A 68-year-old man presented to his local completion of a CT renal mass protocol and
support from the National Cancer Institute (award
emergency department with vomiting and resolution of the gastrointestinal symptoms.
number K07CA133097). The research content is solely
the responsibility of the authors and does not necessarily right upper quadrant pain. The patient had not
represent the official views of the National Cancer experienced symptoms related to urination, fe- The Imaging Question
Institute or the National Institutes of Health. ver, or flank pain. He underwent ultrasound Growth in utilization of radiologic studies
1
examination of the right upper quadrant, has resulted in increased incidental imaging
Department of Radiology, NYU Langone Medical Center,
which showed cholelithiasis and no findings of findings, frequently renal lesions [1, 2]. Most
550 First Ave, New York, NY 10016. Address correspon-
dence to S. K. Kang ([email protected]). cholecystitis. While imaging the right kidney, solid renal tumors are incidentally detected
the sonographer discovered a 2-cm solid right as localized lesions less than 4 cm in diam-
2
Department of Urology, NYU Langone Medical Center, renal mass and notified the radiologist (Fig. 1). eter (stage T1a in the American Joint Com-
New York, NY. The incidental finding prompted further dis- mittee on Cancer staging system [3]), and
3
Department of Radiology, Institute for Technology Assess-
cussion by the emergency department physi- most are treated using the current standard
ment, Massachusetts General Hospital, Boston, MA cian with the patient regarding relevant history of care, nephrectomy, and preferably partial
and a recommendation by the radiologist for a nephrectomy, which has been shown to pre-
AJR 2014; 202:1196–1206 CT to further evaluate the renal mass. serve kidney function and prevent chronic
The patient confirmed that he had no kidney disease [4, 5]. Despite excellent on-
0361–803X/14/2026–1196
known history of malignancy and no symp- cologic control with surgical resection, over-
© American Roentgen Ray Society toms of flank pain or hematuria. Although all survival has not improved in patients with

1196 AJR:202, June 2014

 Solid Renal Masses

Fig. 1—68-year-old man with vomiting and right

upper quadrant pain who underwent ultrasound.
A, Incidental right upper pole renal mass (arrow)
is seen.
B, CT renal mass protocol confirmed 2-cm solid
enhancing mass without distant abdominopelvic
metastases (arrow) that was found to represent clear
cell renal cell carcinoma at surgical pathology.
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A B

small renal cell carcinoma (RCC). In fact, curate discrimination of benign from malig- cell RCC [16]. Of note, papillary RCC com-
nononcologic mortality in affected patients nant solid renal lesions in all cases, nor is prises a heterogeneous subtype of both indo-
has paradoxically increased in the past 2 de- growth on serial imaging statistically differ- lent and also aggressive histologic subtype,
cades, specifically in patients with stage T1a ent in benign and malignant lesions [11–13]. and Pignot and colleagues [17] have shown
RCC [6]. In recognition of such trends, there As a problem-solving tool, MRI offers diag- decreased survival in type 2 versus type 1
may be an increasing need to develop treat- nostic value in further characterizing some papillary cancers.
ment paradigms that better balance oncolog- renal masses, and effective utilization may Large studies have shown that the pap-
ic mortality with competing nononcologic aid management decisions in this generally illary subtype predominates in resect-
and treatment-related risks. elderly patient population with competing ed masses smaller than 2 cm, whereas the
Currently, the major roles of imaging in oncologic and nononcologic mortality risks. clear cell subtype appears most commonly
renal mass management are in characteriz- The purpose of this review is threefold: first, among larger tumors [13, 18]. Rothman and
ing the detected mass, including differentia- to summarize and synthesize the evidence colleagues [7] analyzed Surveillance, Epi-
tion of benign from malignant lesions where regarding renal mass characterization at CT demiology, and End Results Program data
possible, and in staging and preoperative and MRI; second, to provide general diag- of 19,932 localized RCCs and analyzed the
planning. Multiphase CT is currently the im- nostic algorithms for CT and MRI evaluation likelihood of each subtype according to
aging modality of choice for initial diagno- of small renal masses; and third, to provide size; the incidence of papillary RCC formed
sis, staging, and preoperative planning. MRI recommendations regarding future direc- a U-shaped curve, where the likelihood de-
can be useful in some circumstances to fur- tions for imaging research to improve diag- creased with size until lesions reached 10
ther evaluate a renal mass, but what specific nostic utility in renal mass evaluation. Our cm, and then increased in tumors larger
information can it provide, and what is the discussion will apply to the more common than 10 cm.
existing evidence for its added value? Fur- well-circumscribed small renal cortical tu-
thermore, how can evidence-based practice mors and not to lesions displaying clearly ag- Significance of Tumor Size and
be implemented to better evaluate renal le- gressive infiltrating growth patterns, as typi- Growth Rate
sions and to potentially improve patient-cen- cally seen in urothelial tumors. Risk of Malignancy and Prognosis by Size of
tered management? Renal Mass
Synopsis and Synthesis of Evidence: Among the characteristics of a localized
Background Summary of Renal Cell Carcinoma renal mass on initial imaging, tumor size is
Most renal masses are incidentally detect- Subtype Prevalence and Prognosis regarded as the single most important pre-
ed on imaging performed for unrelated symp- Clear cell carcinoma is the most common dictor of malignancy and aggressive histo-
toms or indications. Although most of these of all renal cancer subtypes, accounting for logic grade [8, 18]. Approximately 80% of
lesions are RCC, most are small (i.e., stage approximately 75% of renal cancers, followed small renal masses represent cancers, with
T1a), a substantial portion are benign, and by papillary carcinoma (10%), chromophobe clear cell carcinoma accounting for the vast
some malignant lesions are indolent [7, 8]. (5%), and other unclassified or undifferentiat- majority of malignant lesions [7, 18]. How-
Each of the major imaging modalities of- ed subtypes [14]. Interestingly, the histologic ever, benign lesions increase in prevalence
fers advantages and drawbacks in renal mass subtype has also not been shown consistently as tumor size decreases. Thompson et al.
evaluation. Sonography can be helpful in de- to be a significant predictor of prognosis for [8] examined the proportion of benign le-
termining the cystic nature of a lesion when RCC. A large study by Patard and colleagues sions according to tumor size in 2675 surgi-
a lesion is slightly higher density than flu- [15] showed that TNM stage, Fuhrman grade, cally removed renal masses and found be-
id on CT. However, its use for characteriza- and a clinical performance score, but not his- nign histologic diagnoses in 56% of lesions
tion is generally hampered by low sensitiv- tologic subtype, were independent prognos- 1–2 cm in diameter, decreasing progres-
ity for small lesions, operator dependence, tic variables for overall survival. A trend of sively with increasing size to 13% of mass-
and technical limitations, depending on pa- improved prognosis with chromophobe RCC es at 6–7 cm. These proportions were simi-
tient body habitus and bowel gas [9, 10]. CT was reported in their study [15]; however, oth- lar to values previously reported in a study
currently plays a key role in preoperative re- er studies have reported better overall survival of 2770 resected renal masses by Frank et
nal mass evaluation but does not provide ac- in papillary and chromophobe RCC than clear al. in 2003 [18]. Furthermore, Frank et al.

AJR:202, June 2014 1197

 Kang et al.

Small renal mass

Unenhanced and contrast-enhanced phases Unenhanced phases

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Internal enhancement (≥ 20 HU) Equivocal enhancement No internal enhancement (< 10 HU) Density > 70 HU Bulk fat
(10–20 HU) or other lesion
features limiting assessment Benign, e.g., hemorrhagic or Hemorrhagic Angiomyolipoma
proteinaceous cyst cyst
Avid Low-level
Clear cell RCC Papillary RCC
Chromophobe Consider MRI
RCC for further
Oncocytoma evaluation
Minimal-fat
angiomyolipoma

Surgical candidate
Yes No or borderline

Resection Consider biopsy to

guide treatment
decisions, or
active surveillance

Fig. 2—Diagnostic and management algorithm for small renal mass using CT. RCC = renal cell carcinoma.

reported significant increased odds of clear contradictory study, the size of a small re- Renal Mass Growth Rate Prediction and
cell subtype with increasing size, and both nal mass at presentation was not found to be Significance
studies showed significant increases in ag- an independent prognostic factor in survival The growth rate of small renal masses mon-
gressive histologic grade with increasing or metastatic disease [21]. In terms of met- itored with imaging surveillance has been re-
tumor diameter [8, 18]. astatic disease rates, a large retrospective ported as approximately 0.3 cm [11, 19, 23].
Among localized RCCs smaller than study by Pahernik et al. [13] reported meta- In a single series of surgically resected le-
4 cm, 85% have been reported to represent static rates varying from 2% to 7% in lesions sions with preoperative serial imaging, the le-
low-grade tumors, but high-grade disease smaller than 3 cm [21], whereas Thomp- sion size at presentation did not predict growth
increases with size, with an odds ratio in- son et al. [20] reported de novo metastases rate or histologic grade [23]. Meta-analy-
crease of 13% per centimeter increase in di- in less than 1% of lesions in the same size ses of active surveillance have also reported
ameter [7]. In another large study, among all group. Furthermore, RCCs measuring 4 cm that initial mean tumor diameter did not dif-
lesions up to 4 cm, a minority (≈ 20–25%) have been reported to present with synchro- fer significantly between positive-growth and
showed potentially aggressive features, and nous metastases in up to 6% of cases and ad- zero-growth masses, and that rates of malig-
approximately 70% of lesions larger than vanced stage (pT3) in 12% of cases [13, 22]. nancy were comparable between lesions show-
7 cm also had a low histologic grade [19]. The disagreement among these large studies ing positive and zero growth; however, no me-
The seemingly disparate finding of a large is likely at least partially attributable to de- tastases developed in masses with zero growth
proportion of tumors larger than 7 cm grees of selection bias for patients who are [11, 19]. One of these meta-analyses reported
showing nonaggressive features may be ex- operative candidates, with underrepresenta- that the subgroup of RCCs that were treated
plained partially by selection bias for oper- tion of patients who present with metastat- had a slightly greater growth rate of 0.4 cm
ative candidates with lesions that may have ic disease or are observed without surgical per year, compared with the mean of 0.3 cm
possessed less inherent aggressive potential management. In a meta-analysis of observed [11], and bias in these studies for resection of
(i.e., larger but localized tumors that had enhancing renal masses, the metastatic dis- growing lesions limits definitive correlation of
not developed metastases). ease rate was lower (1%) in lesions smaller growth rate with likelihood of malignancy and
Despite the importance of tumor size in than 3 cm [11], which may reflect selection histologic grade, because not all monitored le-
predicting malignancy and higher histolog- for a more indolent cohort of lesions allowed sions were resected, and the mean follow-up
ic grades of RCC, the association of renal to remain on imaging surveillance. period was generally in the range of 3 years.
mass size with survival remains unclear. Overall, the size of a tumor at initial im- Therefore, the growth rate of a small renal
One large study from a single institution re- aging presentation has been shown to be pre- mass on serial imaging has not been shown to
ported tumor size to be significantly asso- dictive of malignancy and aggressive his- provide reliable prediction of malignancy or
ciated with metastasis-free survival when tologic grade, with weaker evidence for benignity, but growing lesions are more likely
tumors of all sizes were included [20]. In a association with overall survival. to be treated during watchful waiting.

1198 AJR:202, June 2014

 Solid Renal Masses

CT Assessment of Renal Masses An important consideration for the mul- from the clear cell subtype), cholesterol ne-
The renal mass protocol, when performed tiphasic protocol is the increased ionizing crosis, and when a large RCC engulfs peri-
with CT, varies by institution, but standard radiation exposure to the patient, given re- nephric fat [42–44]. In such lesions, calci-
imaging includes an unenhanced phase fol- cent concerns raised regarding risks of ra- fication within a fat-containing mass should
lowed by contrast-enhanced images in the diation-induced cancers after imaging-re- raise suspicion for malignancy [45]. History
nephrographic phase at approximately 90 lated exposures [30–32]. Although the true should also be available to exclude a post-
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seconds after contrast injection. The Amer- risk of radiation-induced cancers remains procedural appearance related to prior par-
ican College of Radiology provides CT as unknown, benefits of deriving further di- tial nephrectomy with fat-packing, or prior
the “most important technique for evaluat- agnostic information should be balanced ablation of a renal mass where the ablation
ing the indeterminate renal mass” [24], but with the possible risks and consideration of zone evolves to a masslike appearance of
recognizes both CT and MRI as appropri- dose-reduction techniques, including the bulk fat [46].
ate initial studies with comparable perfor- use of dual-energy CT or patient-centered Lesion density—The attenuation of
mance in identifying lesions that should protocol optimization [33, 34]. Because the renal parenchyma typically rang-
be surgically managed. The nephrograph- the median patient age at RCC diagnosis is es from 30 to 40 HU; a hyperattenu-
ic phase serves best for detection of a renal 64 years, radiation-induced cancer risks in ating renal mass usually measures be-
mass and also suffices for detection of en- the older patient population are likely min- tween 40 and 90 HU on unenhanced
hancing components. The corticomedullary imal relative to other competing mortality CT images [47]. Lesions with homoge-
(arterial) and urographic (excretory) phas- risks, such as medical comorbidities [35]. neous unenhanced density of more than
es are also often acquired to provide addi- 70 HU have been reported to represent
tional anatomic information for presurgi- Renal Mass Attenuation hemorrhagic cysts more than 99% of the
cal planning and to assess proximity to or Detection of fat—In general, bulk fat time [48]. However, hemorrhagic cysts may
involvement of the collecting system. Use- within a solid renal mass detected on CT is also have density less than 70 HU and are
ful imaging characteristics at CT include a reliable sign of angiomyolipoma. Approx- best confirmed as nonenhancing lesions
the detection of bulk fat, lesion density, and imately 5% of angiomyolipomas contain with unenhanced and contrast-enhanced
enhancement. However, multiple studies minimal fat and pose a diagnostic challenge imaging. A high-density lesion (40–70 HU)
have been performed to assess the perfor- because they currently cannot be reliably is most commonly RCC, but the differen-
mance of enhancement characteristics de- distinguished from RCCs [36]. Although tial diagnosis also includes minimal-fat
rived from multiphase imaging in differen- several studies have reported accurate diag- angiomyolipoma, metanephric adenoma,
tiation of renal tumors with limited success nosis of minimal fat–containing angiomyo- leiomyoma, oncocytomas, and other mes-
[25–29]. A general diagnostic algorithm is lipomas using pixel or histogram analyses enchymal and metanephric lesions that
presented for CT evaluation, which includes [37–39], the findings have not been repro- overlap in appearance with RCC [50]. Pri-
potential circumstances where MRI may ducible [40, 41]. or studies support consideration of a min-
provide additional information for manage- Rarely, macroscopic fat may also appear imal-fat angiomyolipoma when evaluating
ment decisions (Fig. 2). in RCC with osseous metaplasia (usually an enhancing high-attenuation lesion at CT

TABLE 1: Summary Comparison of Studies Examining Differentiation of Renal Cell Carcinoma (RCC) From Oncocytoma
Imaging Comparison RCC Characteristics of
Reference Modality Subtype Imaging Criteria Reported Results Tumors
Young et al. [25] CT Clear cell Threshold attenuation values in three phases 84% accuracy (81/97) All sizes
Wildberger et CT Clear cell Qualitative features: solid, well-demarcated, 12.2% (6/49) observations All sizes
al. [57] central scar, spoke wheel pattern, hypodense correct for oncocytoma
after contrast agent administration
Bird et al. [58] CT All subtypes Attenuation in three phases, percentage change p < 0.05, using Student t test for < 4 cm, RCC group: 60%
RCC vs oncocytoma clear cell
Davidson et al. CT All subtypes Homogeneous enhancement and central sharply No difference in small and large All sizes
[59] marginated scar tumors, 33% called RCC
Zhang et al. [26] CT Clear cell Qualitative features, enhancement in two phases No difference All sizes, with small
number oncocytoma
Cornelis et al. MRI Clear cell Segmental inversion after 5-min delay, and 55% sensitivity, 97% specificity, All sizes
[68] tumor-to-spleen signal intensity ratio 86% PPV, 88% NPV
Rosenkrantz et MRI Chromophobe Qualitative features, segmental inversion after 10% of chromophobe, All sizes, most < 4 cm
al. [67] 3-min delay oncocytoma with segmental
inversion
Taouli et al. [69] MRI All subtypes (solid DWI in addition to contrast-enhanced MRI, 90% sensitivity, 83% specificity, All sizes ≥ 1 cm
tumors only) ADC cutoff of ≤ 1.66 × 10 –3 mm 2 /s (at b values AUC 0.854 for solid RCC
0, 400, 800)
Note—PPV = positive predictive value, NPV = negative predictive value, DWI = diffusion-weighted imaging, ADC = apparent diffusion coefficient, AUC = area under the curve.

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 Kang et al.
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A B C

D E F
Fig. 3—54-year-old woman with left renal mass at CT and clinical diagnosis of pyelonephritis.
A and B, CT images with (A) and without (B) contrast agent show apparent left upper pole mass (arrows) with
hypoenhancement relative to renal parenchyma.
C, Enlarged retroperitoneal lymph nodes (arrow) are also present.
D and E, Dynamic contrast-enhanced MRI 1 week later shows slightly smaller lesion (arrows), with
corticomedullary differentiation internally (D) and continued hypoenhancement relative to parenchyma in
nephrographic phase (E).
F and G, Lesion (arrows) also shows marked restricted diffusion (F) with loss of signal on corresponding
apparent diffusion coefficient map (G). Focal pyelonephritis was diagnosed and resolved at follow-up MRI.

[36, 52]. Still, biopsy remains necessary at tion and also with masses smaller than 1 cm, Some similarities and differences in en-
this time to determine the diagnosis because limiting CT assessment in such cases [55]. hancement peaks and patterns have been re-
of an overlap in appearance with RCC [53]. When the attenuation change falls within ported among oncocytomas and RCC sub-
Lesions that appear lower density than the 10–20 HU, subtraction imaging at MRI may types and are summarized here. In a study
renal parenchyma include renal cystic lesions, be useful if available [56]. of 298 renal tumors of varying size, both
focal pyelonephritis, abscess, and papillary Perhaps the most clinically relevant im- clear cell RCC and oncocytomas peaked in
RCCs. In such cases, where clinical history is aging challenge for the localized small renal the corticomedullary phase [25]. In terms
not informative or may be confounding, MRI tumor remains distinguishing RCC from be- of enhancement pattern, oncocytomas have
may aid in further differentiating among these nign solid lesions, particularly oncocytomas been reported to show a “segmental inver-
benign and malignant diagnoses (Fig. 3). and minimal-fat angiomyolipomas. Though sion” pattern on enhanced phases [60], but
multiple investigations have examined quali- these findings have not been consistently re-
Qualitative and Quantitative Enhancement tative and quantitative methods of analyzing producible [61–63]. Furthermore, a central
Enhancement is defined as an increase enhancement to distinguish RCC from on- scar is present in the minority of cases [64].
in attenuation by 20 HU or more on con- cocytoma, no enhancement characteristics To date, to our knowledge, no qualitative im-
trast-enhanced images compared with un- have been shown to accurately and repro- aging features have been shown to reliably
enhanced images because lesser degrees of ducibly distinguish oncocytoma from RCC diagnose oncocytomas at CT.
change in attenuation value may be attribut- [25, 26, 57–59] (Table 1). Furthermore, the Absolute peak attenuation values have
able to pseudoenhancement [54]. The phe- degree of heterogeneity of protocols and study also been studied for discrimination of RCC
nomenon of pseudoenhancement is known to design prevent a meta-analytic approach to from oncocytomas. Young et al. [25] found
be significantly associated with central loca- synthesize the available published data. that clear cell RCC was differentiated from

1200 AJR:202, June 2014

 Solid Renal Masses

oncocytoma with an accuracy of 77%, sensi- gree of enhancement and inherent density, mas and angiomyolipomas tend to show early
tivity of 86%, and positive predictive value of but, in cases without bulk fat, cannot dis- enhancement in the corticomedullary phase
85% using attenuation thresholds of 106 HU criminate benign from malignant tumors. followed by lower level enhancement in lat-
in the corticomedullary phase, 92 HU in the When initial characterization with CT leaves er phases, and low-level late enhancement is
nephrographic phase, and 68 HU in the ex- a question about the presence of enhanc- more typical of papillary RCC [25, 66]. Stud-
cretory phase. The authors’ institution used ing components or a nontumorous lesion, as ies examining the differentiation of clear
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a four-phase CT protocol and did not limit summarized in the provided diagnostic algo- cell and chromophobe RCC from oncocyto-
the size of the evaluated lesions [25]. Giv- rithm (Fig. 2), MRI may offer further prob- mas using enhancement characteristics have
en the lack of a standardized protocol across lem-solving capability. reported variable results [67–69], but as in
institutions, quantitative use of enhancement studies using CT, small lesions may be less
should be examined in a larger study to fur- MRI Assessment of Renal Masses likely to show the reported features that dif-
ther evaluate the diagnostic value of absolute MRI most often complements CT in renal ferentiate RCC from oncocytoma (Table 1).
attenuation changes. mass characterization, although it may also be The heterogeneity of study design and MRI
RCC is also not reliably distinguished from used as the initial dedicated study for evalua- techniques among these small studies does
minimal-fat angiomyolipomas using enhance- tion of a renal mass under current American not support performance of meta-analysis.
ment characteristics. In addition to being adi- College of Radiology guidelines [24]. Com- Complex cystic renal lesions and papillary
pose rich or poor, angiomyolipomas vary in pared with CT, patient-level factors, such as RCCs may have a similar appearance at CT,
composition of smooth muscle and vascu- the ability to tolerate longer scan time and co- due to hypoattenuation, minimal appreciable
lar and epithelioid elements, which leads to a operate with breath-holding, may lead to more heterogeneity, and enhancement; more dis-
variable imaging appearance [65]. In several potential variability in diagnostic quality. tinctive features at MRI can aid in delineat-
small series, minimal-fat angiomyolipomas Just as with CT, the detection of internal en- ing the tumor types and specifically identify
have been described to show homogeneous hancing soft tissue is of primary importance. enhancing tissue (Fig. 5). The distinction may
enhancement in addition to hyperdensity rel- Routinely performed sequences in the MRI be useful in poor surgical candidates to assess
ative to renal parenchyma [36, 51, 52]. Al- protocol for renal mass evaluation include prognostic implications, or to better identify
though some differences have also been de- T2-weighted imaging, T1-weighted opposed- a specific portion of tumor to target in biopsy
scribed in enhancement kinetics among RCC phase imaging (in-phase and out-of-phase if pretreatment diagnosis is desired [70–72].
subtypes and minimal-fat angiomyolipomas, sequences), and fat-suppressed T1-weighted
Yang and colleagues [53] examined the poten- gradient-echo acquisition before and after ad- Unenhanced Sequences
tially predictive imaging variables and found ministration of IV gadolinium-based contrast T2-weighted imaging—T2 signal intensi-
that unenhanced high density was the only ex- medium in corticomedullary, nephrographic, ty can be somewhat helpful if it is used in a
amined variable that consistently and signifi- and urographic phases of enhancement. Dif- solid renal mass to assess the likelihood of
cantly differentiated minimal-fat angiomyo- fusion-weighted imaging (DWI) can improve a papillary RCC or minimal-fat angiomyoli-
lipomas from RCC. Despite the inability to diagnostic confidence, and the use of appar- poma because of low T2 signal. T2 hyperin-
completely exclude RCC with homogeneous ent diffusion coefficient (ADC) values for dis- tensity is typically seen in clear cell tumors
enhancement and intrinsic hyperattenuation, criminating between benign and malignant but is not specific, because this characteris-
minimal-fat angiomyolipoma may be impor- lesions and among RCC subtypes is also un- tic can also be seen in oncocytomas and in a
tant to specify in the differential diagnosis der active investigation. minority of chromophobe carcinomas [67].
because surveillance or biopsy may be under MRI offers problem-solving capability in Hindman et al. [73] examined the ability
consideration for poor surgical candidates. some scenarios where CT may be limited in to distinguish between minimal-fat angio-
Among RCC subtypes, papillary RCC identifying enhancing soft tissue and can pro- myolipoma (< 25% lipid content at histopa-
has been found to show lesser degrees of en- vide an accurate diagnosis of a cyst or solid thology) and clear cell RCC and found that
hancement than other subtypes of RCC and, mass through synthesis of signal characteris- low T2 signal was the only imaging feature,
in some cases, may be mistaken for renal tics and subtraction imaging [56]. In primary aside from small size, that predicted mini-
cysts because of low-level enhancement [66]. lesion assessment, the combination of lesion mal-fat angiomyolipoma in multivariate lo-
In a study examining differentiation of the characteristics across multiple sequences can gistic regression. In another study of clear
clear cell from the papillary subtype, attenu- suggest the differential diagnosis, as present- cell and papillary RCC, low T2 signal was
ation less than 100 HU in the corticomedul- ed in a general diagnostic algorithm (Fig. 4). 100% specific in discriminating papillary
lary phase of enhancement was 95.7% specif- However, just as with CT, MRI cannot yet dif- RCC from the clear cell subtype; thus, low
ic after normalization for aortic enhancement ferentiate benign and malignant tumors, aside T2 signal is not a specific indicator of be-
[29]. Both papillary and chromophobe RCC from classic angiomyolipomas. nign histologic subtype [74].
have been shown to peak in the nephrographic T1-weighted imaging—The detection of
phase, later than clear cell RCC [25]. Qualita- Enhancement bulk fat on MRI is accomplished through
tively, papillary RCCs have been reported to In lesions with intrinsically T1-hyperin- T1-weighted imaging with and without fat
show variable patterns of either homogeneous tense components, subtraction can be help- suppression, or T1-weighted in-phase and
or heterogeneous enhancement [26–28]. ful to determine the presence of enhance- out-of-phase imaging using the India ink
Overall, CT assessment can provide lim- ment [56]. Enhancement kinetics have also artifact [75]. Microscopic fat detected as
ited information to assess the likelihood of been studied for differentiating tumor types loss of signal on out-of-phase imaging can-
certain RCC subtypes according to the de- at MRI; just as with CT, clear cell carcino- not be used reliably to discriminate between

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 Kang et al.

Small renal mass

Non-T1 hyperintense T1 hyperintense

Enhancement No internal enhancement Enhancing components No enhancements

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Hemorrhagic or
proteinaceous cyst
T2-weighted imaging DWI restriction No DWI restriction No fat Fat
Abscess Benign RCC
Infarct (e.g., cyst) Minimal-fat AML
Dark Isointense to bright
Microscopic Macroscopic
Clear cell RCC
Chromophobe RCC Angiomyolipoma Angiomyolipoma
Oncocytoma Clear cell RCC
Low-level Avid Minimal-fat
enhancement enhancement angiomyolipoma
Papillary RCC Minimal-fat Lymphoma
Minimal-fat angiomyolipoma
angiomyolipoma Chromophobe RCC Surgical candidate
Solitary fibrous Oncocytoma
tumor if capsular Lymphoma Yes No or borderline

Resection Consider biopsy to

Surgical candidate guide treatment
decisions, or active
Yes No or borderline
surveillance

Resection Consider biopsy to

guide treatment
decisions or active
surveillance

Fig. 4—Diagnostic and management algorithm for small renal mass using MRI, provided diagnoses are favored given lesion characteristics; however, overlap remains
between benign lesions and renal cell carcinoma (RCC) and among RCC subtypes. AML = angiomyolipoma; DWI = diffusion-weighted imaging.

A B
Fig. 5—67-year-old man with hypoattenuating left
renal mass at CT who underwent further evaluation
with MRI.
A, Contrast-enhanced CT shows hypoattenuating
(25 HU) left renal mass (arrow), with borderline
enhancement internally.
B, At MRI, coronal HASTE shows lesion (arrow) to be
predominantly T2 dark.
C, Axial T1-weighted image shows hyperintense
layering posterior component (arrow).
D, MRI subtraction image shows anterior enhancing
soft tissue and confirms nonenhancing posteriorly
layering hemorrhage (arrow). Papillary renal cell
carcinoma was diagnosed at surgical pathology.
C D

1202 AJR:202, June 2014

 Solid Renal Masses

angiomyolipomas containing minimal fat, mity of techniques for DWI limits the routine [84–86]. With improvements in imaging-
because clear cell RCCs may also contain use of ADC values, findings suggest potential guided percutaneous techniques and cumu-
microscopic fat [73]. value for improving the clinical performance lative reported experience in the literature,
Lesions that are intrinsically T1 hyper- of MRI and warrant larger, ideally multiin- data support a minimal risk of tract seed-
intense but show no evidence of fat are most stitutional, studies with standardized param- ing and an up to 99% rate of pathologic di-
likely hemorrhagic or proteinaceous cysts, and eters and b values to establish the reliability of agnoses with biopsy [87, 88]. Given these fa-
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subtraction imaging can be helpful to assess ADC values across scanner types. vorable findings and considering the older
for underlying enhancing components. Among population in which small renal masses are
solid lesions, both benign and malignant le- Evidence-Based Guidelines usually discovered, renal mass biopsy may
sions can show T1 hyperintensity because of Recognizing that management of ear- play an increasingly integral role in the near
blood products or proteinaceous contents; hem- ly-stage renal cancers with uniformly ag- future if greater emphasis is placed on pa-
orrhage is seen in RCC (particularly within the gressive treatment has not improved patient tient-centered management.
clear cell and papillary subtypes) but may also health outcomes, imagers may offer helpful Further advances in immunohistochemi-
be seen in benign solid neoplasms, such as on- guidance to patients and referring physicians cal analysis may also support improved man-
cocytomas, metanephric tumors, or angiomyo- through knowledge of how CT, MRI, or bi- agement decisions using renal mass biopsy.
lipomas [72, 76]. In addition, the presence of opsy can best inform decision making. We Historically, the distinction of epithelioid an-
hemorrhage or hemosiderin within a mass with offer general guidelines for using MRI as a giomyolipoma from sarcomatoid RCC may
enhancing soft tissue is not a distinguishing problem-solving tool for renal mass evalu- have been problematic at pathology, but cur-
characteristic among RCC subtypes [67, 74]. ation, with the caveat that the decision re- rent immunohistochemical evaluation makes
Diffusion-weighted imaging—DWI may quires consideration of patient-level factors the diagnosis with high accuracy [89]. The
particularly be helpful in lesion detection and in the management of renal masses. Al- diagnosis of chromophobe carcinoma or on-
evaluation when gadolinium-based contrast though CT and MRI offer similar abilities cocytoma remains a challenge at pathology,
medium cannot be administered. It can also for diagnosis, staging, and preoperative ana- however, because of the overlap in features.
aid in differentiating some benign and ma- tomic delineation, MRI may offer more sen-
lignant lesions [77–79]. Visual inspection of sitive and specific evaluation when the pa- Outstanding Issues That
DWI can assist with lesion detection and, for tient cannot receive iodinated contrast agent Warrant Research
certain lesions, reinforce the likelihood of a or when the lesion has features limiting as- The radiologic discrimination of benign,
pseudolesion. Although investigators have sessment at CT, such as endophytic property, indolent, and aggressive malignant renal
examined the use of ADC values to predict small size (≈ 1 cm), equivocal enhancement, masses remains the diagnostic challenge of
RCC subtypes and separate benign from ma- or confluent areas of dense calcification [55, high clinical relevance. The current need for
lignant lesions, their use is limited by the fact 54] (Fig. 2). In such cases of low-level or un- tissue-based diagnosis and prevalent treat-
that that there is substantial inter- and intra- clear enhancing components, subtraction im- ment pattern of nearly nondiscriminatory
scanner variability in ADC measurement, ages at MRI may allow ascertainment of a extirpation encourage key areas for research
and ADC values depend on selected b val- benign cyst, precluding the need for surgery. in imaging evaluation of the small renal
ues that vary across institutions and protocols MRI can offer incremental value after mass. These key areas include reliable di-
[9, 10, 79]. That said, ADC has been shown CT when patients may not be strong candi- agnosis of the most common benign lesions
to be significantly lower in renal disease (both dates to undergo standard surgical treatment. and the ability to predict tumor aggressive-
malignant and nonmalignant processes such When a possible diagnosis of minimal-fat an- ness in malignancies. Positive findings in
as infection) than in normal renal parenchy- giomyolipoma is suggested at CT, supportive these areas have been reported in relatively
ma [80–82]. Small studies have shown the findings for the same diagnosis at MRI may small studies with highly variable imaging
potential value of DWI for helping to differ- prompt biopsy and avoid surgery. Similarly, techniques, limiting application of the evi-
entiate between benign and malignant masses a mildly complex questionably enhancing dence at this time. The incremental value of
[69, 78]. Kim et al. [77] also showed improved low-density lesion at CT may be a predomi- recently developed quantitative techniques,
accuracy with the addition of DWI in differ- nantly cystic lesion or a papillary RCC, and such as DWI including intravoxel incoher-
entiating benign from malignant T1-hyperin- enhancement and T2 characteristics at MRI ent motion or arterial spin labeling [90, 91],
tense lesions at unenhanced MRI. may inform the decision to perform biopsy or warrant larger studies because morphologic
Studies have also examined the use of ADC monitor a mass in select patients. For border- characteristics and quantitative assessment
values in discriminating among RCC sub- line or poor surgical candidates in particular, derived from conventional imaging have
types. A lower ADC has been reported in substantial changes in the posttest probability been well studied and have not performed
the papillary subtype of RCC compared with of a benign or indolent lesion may influence reliably in distinguishing benign and malig-
other subtypes at both 1.5 and 3 T [69, 80], the pursuit of biopsy, active surveillance, or nant tumors. Larger, multiinstitutional stud-
whereas clear cell RCC showed a significant- percutaneous ablative therapy. ies would better establish the performance
ly higher ADC than other subtypes at 3 T [80, Renal mass biopsy was not historically of CT and MRI and address these questions
82]. ADC has also been found to be signif- favored by urologists because of perceived of high clinical relevance.
icantly lower in high-nuclear-grade (III and risks of tract-seeding, sampling error, in- Targeted imaging agents may also in the
IV) than in low-nuclear-grade (I and II) clear ability for pathologic diagnosis in a substan- future allow greater sensitivity and specifici-
cell tumors at 1.5 T [83] and between grades tial proportion of cases, and risk of peripro- ty in lesion characterization; one such target-
at 3 T [82]. Although the current nonunifor- cedural complications such as hemorrhage ed agent for PET/CT of clear cell RCC has

AJR:202, June 2014 1203

 Kang et al.

already undergone testing in patients [92]. masses: a need to reassess treatment effect. J Natl size does not predict risk of metastatic disease or
In the absence of reliable imaging markers Cancer Inst 2006; 98:1331–1334 prognosis of small renal cell carcinomas. J Urol
of aggressiveness, renal mass biopsy may 7. Rothman J, Egleston B, Wong YN, Iffrig 2008; 179:1719–1726
be further studied as a more frequently used K, Lebovitch S, Uzzo RG. Histopathological char- 22. Nguyen MM, Gill IS. Effect of renal cancer size
guide in treatment selection. In addition to acteristics of localized renal cell carcinoma cor- on the prevalence of metastasis at diagnosis and
providing histologic subtype, biopsy speci- relate with tumor size: a SEER analysis. J Urol mortality. J Urol 2009; 181:1020–1027; discus-
Downloaded from www.ajronline.org by 177.57.155.114 on 10/27/24 from IP address 177.57.155.114. Copyright ARRS. For personal use only; all rights reserved

mens may in the future allow testing for spe- 2009; 181:29–33; discussion, 33–34 sion, 1027
cific protein expression or genetic mutations 8. Thompson RH, Kurta JM, Kaag M, et al. Tumor 23. Zhang J, Kang SK, Wang L, Touijer A, Hricak H.
and guide targeted chemotherapy and prog- size is associated with malignant potential in renal Distribution of renal tumor growth rates deter-
nostication more so than the morphology- cell carcinoma cases. J Urol 2009; 181:2033–2036 mined by using serial volumetric CT measure-
based Fuhrman grading system. 9. Jamis-Dow CA, Choyke PL, Jennings SB, Line- ments. Radiology 2009; 250:137–144
han WM, Thakore KN, Walther MM. Small 24. American College of Radiology. ACR appropri-
Conclusion (< or = 3-cm) renal masses: detection with CT ateness criteria: indeterminate renal masses.
Considerable challenges remain in the versus US and pathologic correlation. Radiology American College of Radiology website. www.acr.
imaging of small renal mass. Given the in- 1996; 198:785–788 org/~/media/ACR/Documents/Appcriteria/Diag-
cidental nature of many lesions, overall in- 10. Hoffmann U, Edwards JM, Carter S, et al. Role of nostic/IndeterminateRenalMasses.pdf. Published
dolence of small renal masses, and lack of duplex scanning for the detection of atheroscle- 1996. Updated 2010. Accessed December 19, 2013
improved outcomes for this older patient rotic renal artery disease. Kidney Int 1991; 25. Young JR, Margolis D, Sauk S, Pantuck AJ, Sayre
population, despite downward stage migra- 39:1232–1239 J, Raman SS. Clear cell renal cell carcinoma: dis-
tion in renal cancer, imaging evaluation may 11. Chawla SN, Crispen PL, Hanlon AL, Greenberg crimination from other renal cell carcinoma sub-
play an increasingly important role for de- RE, Chen DY, Uzzo RG. The natural history of types and oncocytoma at multiphasic multidetec-
cision makers in the selection of treatment. observed enhancing renal masses: meta-analysis tor CT. Radiology 2013; 267:444–453
CT and MRI provide similar assessment of and review of the world literature. J Urol 2006; 26. Zhang J, Lefkowitz RA, Ishill NM, et al. Solid
renal masses, but MRI may better depict en- 175:425–431 renal cortical tumors: differentiation with CT. Ra-
hancing components in some circumstanc- 12. Kunkle DA, Crispen PL, Chen DY, Green- diology 2007; 244:494–504
es. MRI can also potentially provide in- berg RE, Uzzo RG. Enhancing renal masses with 27. Kim JK, Kim TK, Ahn HJ, Kim CS, Kim KR,
cremental value after CT findings when a zero net growth during active surveillance. J Urol Cho KS. Differentiation of subtypes of renal cell
benign mass or pseudolesion is questioned, 2007; 177:849–853; discussion, 853–844 carcinoma on helical CT scans. AJR 2002;
or for soft-tissue targeting in biopsy for a 13. Pahernik S, Ziegler S, Roos F, Melchior SW, Thu- 178:1499–1506
low-attenuation lesion. Larger studies must roff JW. Small renal tumors: correlation of clini- 28. Herts BR, Coll DM, Novick AC, et al. Enhance-
be conducted to determine the diagnostic cal and pathological features with tumor size. J ment characteristics of papillary renal neoplasms
performance of newer imaging techniques Urol 2007; 178:414–417; discussion, 416–417 revealed on triphasic helical CT of the kidneys.
for predicting benignity and metastatic po- 14. Reuter VE. The pathology of renal epithelial neo- AJR 2002; 178:367–372
tential, and thus more definitively establish plasms. Semin Oncol 2006; 33:534–543 29. Ruppert-Kohlmayr AJ, Uggowitzer M, Meiss-
the role of imaging-based management in 15. Patard JJ, Leray E, Rioux-Leclercq N, et nitzer T, Ruppert G. Differentiation of renal clear
shifting renal mass treatment paradigms and al. Prognostic value of histologic subtypes in renal cell carcinoma and renal papillary carcinoma us-
improving patient health outcomes. cell carcinoma: a multicenter experience. J Clin ing quantitative CT enhancement parameters.
Oncol 2005; 23:2763–2771 AJR 2004; 183:1387–1391
References 16. Cheville JC, Lohse CM, Zincke H, Weaver AL, 30. Smith-Bindman R. Is computed tomography safe?
1. Gill IS, Aron M, Gervais DA, Jewett MA. Clini- Blute ML. Comparisons of outcome and prognos- N Engl J Med 2010; 363:1–4
cal practice: small renal mass. N Engl J Med 2010; tic features among histologic subtypes of renal cell 31. Smith-Bindman R, Lipson J, Marcus R, et al. Ra-
362:624–634 carcinoma. Am J Surg Pathol 2003; 27:612–624 diation dose associated with common computed
2. Jayson M, Sanders H. Increased incidence of ser- 17. Pignot G, Elie C, Conquy S, et al. Survival analy- tomography examinations and the associated life-
endipitously discovered renal cell carcinoma. sis of 130 patients with papillary renal cell carci- time attributable risk of cancer. Arch Intern Med
Urology 1998; 51:203–205 noma: prognostic utility of type 1 and type 2 sub- 2009; 169:2078–2086
3. American Joint Committee on Cancer. Kidney. classification. Urology 2007; 69:230–235 32. Brenner DJ, Doll R, Goodhead DT, et al. Cancer
In: Edge SB, Byrd DR, Compton CC, et al., eds. 18. Frank I, Blute ML, Cheville JC, Lohse CM, risks attributable to low doses of ionizing radia-
AJCC cancer staging manual. 7th ed. New York: Weaver AL, Zincke H. Solid renal tumors: an tion: assessing what we really know. Proc Natl
Springer, 2010:479–489 analysis of pathological features related to tumor Acad Sci USA 2003; 100:13761–13766
4. Campbell SC, Novick AC, Belldegrun A, et al. size. J Urol 2003; 170:2217–2220 33. Prakash P, Kalra MK, Kambadakone AK, et al.
Guideline for management of the clinical T1 renal 19. Smaldone MC, Kutikov A, Egleston BL, et al. Reducing abdominal CT radiation dose with
mass. J Urol 2009; 182:1271–1279 Small renal masses progressing to metastases un- adaptive statistical iterative reconstruction tech-
5. Huang WC, Levey AS, Serio AM, et al. Chronic der active surveillance: a systematic review and nique. Invest Radiol 2010; 45:202–210
kidney disease after nephrectomy in patients with pooled analysis. Cancer 2012; 118:997–1006 34. Graser A, Johnson TR, Hecht EM, et al. Dual-
renal cortical tumours: a retrospective cohort 20. Thompson RH, Hill JR, Babayev Y, et al. Meta- energy CT in patients suspected of having renal
study. Lancet Oncol 2006; 7:735–740 static renal cell carcinoma risk according to tumor masses: can virtual nonenhanced images replace
6. Hollingsworth JM, Miller DC, Daignault S, Hol- size. J Urol 2009; 182:41–45 true nonenhanced images? Radiology 2009;
lenbeck BK. Rising incidence of small renal 21. Klatte T, Patard JJ, de Martino M, et al. Tumor 252:433–440

1204 AJR:202, June 2014

 Solid Renal Masses

35. Surveillance, Epidemiology, and End Results Pro- plasms: correlation with pathologic findings and MDCT a reliable sign for the noninvasive diagno-
gram. SEER cancer statistics review, 1975–2003. tumor angiogenesis. J Comput Assist Tomogr sis of renal oncocytomas? AJR 2011; 197:[web]
National Cancer Institute website. www.seer.can- 2000; 24:835–842 W674–W679
cer.gov/csr/1975_2003/. Published April 2006. 50. Fielding JR, Visweswaran A, Silverman SG, 63. O’Malley ME, Tran P, Hanbidge A, Rogalla P.
Accessed September 25, 2013 Granter SR, Renshaw AA. CT and ultrasound fea- Small renal oncocytomas: is segmental enhance-
36. Jinzaki M, Tanimoto A, Narimatsu Y, et al. An- tures of metanephric adenoma in adults with ment inversion a characteristic finding at biphasic
Downloaded from www.ajronline.org by 177.57.155.114 on 10/27/24 from IP address 177.57.155.114. Copyright ARRS. For personal use only; all rights reserved

giomyolipoma: imaging findings in lesions with pathologic correlation. J Comput Assist Tomogr MDCT? AJR 2012; 199:1312–1315
minimal fat. Radiology 1997; 205:497–502 1999; 23:441–444 64. Choudhary S, Rajesh A, Mayer NJ, Mulcahy KA,
37. Simpfendorfer C, Herts BR, Motta-Ramirez GA, 51. Hafron J, Fogarty JD, Hoenig DM, Li M, Berken- Haroon A. Renal oncocytoma: CT features can-
et al. Angiomyolipoma with minimal fat on blit R, Ghavamian R. Imaging characteristics of not reliably distinguish oncocytoma from other
MDCT: can counts of negative-attenuation pixels minimal fat renal angiomyolipoma with histolog- renal neoplasms. Clin Radiol 2009; 64:517–522
aid diagnosis? AJR 2009; 192:438–443 ic correlations. Urology 2005; 66:1155–1159 65. Lane BR, Aydin H, Danforth TL, et al. Clinical cor-
38. Simpson E, Patel U. Diagnosis of angiomyolipo- 52. Kim JK, Park SY, Shon JH, Cho KS. Angiomyoli- relates of renal angiomyolipoma subtypes in 209
ma using computed tomography: region of inter- poma with minimal fat: differentiation from renal patients: classic, fat poor, tuberous sclerosis associ-
est ≤ −10 HU or 4 adjacent pixels ≤ −10 HU are cell carcinoma at biphasic helical CT. Radiology ated and epithelioid. J Urol 2008; 180:836–843
recommended as the diagnostic thresholds. Clin 2004; 230:677–684 66. Egbert ND, Caoili EM, Cohan RH, et al. Differen-
Radiol 2006; 61:410–416 53. Yang CW, Shen SH, Chang YH, et al. Are there tiation of papillary renal cell carcinoma subtypes
39. Kim JY, Kim JK, Kim N, Cho KS. CT histogram useful CT features to differentiate renal cell carci- on CT and MRI. AJR 2013; 201:347–355
analysis: differentiation of angiomyolipoma with- noma from lipid-poor renal angiomyolipoma? 67. Rosenkrantz AB, Hindman N, Fitzgerald EF,
out visible fat from renal cell carcinoma at CT AJR 2013; 201:1017–1028 Niver BE, Melamed J, Babb JS. MRI features of
imaging. Radiology 2008; 246:472–479 54. Birnbaum BA, Hindman N, Lee J, Babb JS. Renal renal oncocytoma and chromophobe renal cell
40. Catalano OA, Samir AE, Sahani DV, Hahn PF. cyst pseudoenhancement: influence of multidetec- carcinoma. AJR 2010; 195:[web]W421–W427
Pixel distribution analysis: can it be used to distin- tor CT reconstruction algorithm and scanner type 68. Cornelis F, Lasserre AS, Tourdias T, et al. Com-
guish clear cell carcinomas from angiomyolipomas in phantom model. Radiology 2007; 244:767–775 bined late gadolinium-enhanced and double-echo
with minimal fat? Radiology 2008; 247:738–746 55. Tappouni R, Kissane J, Sarwani N, Lehman EB. chemical-shift MRI help to differentiate renal onco-
41. Chaudhry HS, Davenport MS, Nieman CM, Ho Pseudoenhancement of renal cysts: influence of le- cytomas with high central T2 signal intensity from
LM, Neville AM. Histogram analysis of small sion size, lesion location, slice thickness, and num- renal cell carcinomas. AJR 2013; 200:830–838
solid renal masses: differentiating minimal fat an- ber of MDCT detectors. AJR 2012; 198:133–137 69. Taouli B, Thakur RK, Mannelli L, et al. Renal le-
giomyolipoma from renal cell carcinoma. AJR 56. Hecht EM, Israel GM, Krinsky GA, et al. Renal sions: characterization with diffusion-weighted
2012; 198:377–383 masses: quantitative analysis of enhancement imaging versus contrast-enhanced MR imaging.
42. Lesavre A, Correas JM, Merran S, Grenier N, with signal intensity measurements versus quali- Radiology 2009; 251:398–407
Vieillefond A, Helenon O. CT of papillary renal tative analysis of enhancement with image sub- 70. Bielsa O, Lloreta J, Gelabert-Mas A. Cystic renal cell
cell carcinomas with cholesterol necrosis mim- traction for diagnosing malignancy at MR imag- carcinoma: pathological features, survival and impli-
icking angiomyolipomas. AJR 2003; 181:143–145 ing. Radiology 2004; 232:373–378 cations for treatment. Br J Urol 1998; 82:16–20
43. Richmond L, Atri M, Sherman C, Sharir S. Renal 57. Wildberger JE, Adam G, Boeckmann W, et al. 71. Han KR, Janzen NK, McWhorter VC, et al. Cystic
cell carcinoma containing macroscopic fat on CT Computed tomography characterization of renal renal cell carcinoma: biology and clinical behav-
mimics an angiomyolipoma due to bone metapla- cell tumors in correlation with histopathology. In- ior. Urol Oncol 2004; 22:410–414
sia without macroscopic calcification. Br J Radiol vest Radiol 1997; 32:596–601 72. Webster WS, Thompson RH, Cheville JC, Lohse
2010; 83:e179–e181 58. Bird VG, Kanagarajah P, Morillo G, et al. Differ- CM, Blute ML, Leibovich BC. Surgical resection
44. Prando A. Intratumoral fat in a renal cell carci- entiation of oncocytoma and renal cell carcinoma provides excellent outcomes for patients with cys-
noma. AJR 1991; 156:871 in small renal masses (<4 cm): the role of 4-phase tic clear cell renal cell carcinoma. Urology 2007;
45. Silverman SG, Israel GM, Herts BR, Richie JP. computerized tomography. World J Urol 2011; 70:900–904; discussion, 904
Management of the incidental renal mass. Radiol- 29:787–792 73. Hindman N, Ngo L, Genega EM, et al. Angiomyoli-
ogy 2008; 249:16–31 59. Davidson AJ, Hayes WS, Hartman DS, McCarthy poma with minimal fat: can it be differentiated from
46. Wile GE, Leyendecker JR, Krehbiel KA, WF, Davis CJ Jr. Renal oncocytoma and carcino- clear cell renal cell carcinoma by using standard MR
Dyer RB, Zagoria RJ. CT and MR imaging after ma: failure of differentiation with CT. Radiology techniques? Radiology 2012; 265:468–477
imaging-guided thermal ablation of renal neo- 1993; 186:693–696 74. Oliva MR, Glickman JN, Zou KH, et al. Renal
plasms. RadioGraphics 2007; 27:325–339; dis- 60. Kim JI, Cho JY, Moon KC, Lee HJ, Kim SH. Seg- cell carcinoma: T1 and T2 signal intensity charac-
cussion, 339–340 mental enhancement inversion at biphasic multi- teristics of papillary and clear cell types correlat-
47. Bosniak MA. The small (less than or equal to 3.0 detector CT: characteristic finding of small renal ed with pathology. AJR 2009; 192:1524–1530
cm) renal parenchymal tumor: detection, diagnosis, oncocytoma. Radiology 2009; 252:441–448 75. Israel GM, Hindman N, Hecht E, Krinsky G. The
and controversies. Radiology 1991; 179:307–317 61. Woo S, Cho JY, Kim SH, Kim SY. Comparison of use of opposed-phase chemical shift MRI in the
48. Jonisch AI, Rubinowitz AN, Mutalik PG, Israel segmental enhancement inversion on biphasic diagnosis of renal angiomyolipomas. AJR 2005;
GM. Can high-attenuation renal cysts be differen- MDCT between small renal oncocytomas and 184:1868–1872
tiated from renal cell carcinoma at unenhanced chromophobe renal cell carcinomas. AJR 2013; 76. Chandarana H, Kang SK, Wong S, et al. Diffu-
CT? Radiology 2007; 243:445–450 201:598–604 sion-weighted intravoxel incoherent motion imag-
49. Jinzaki M, Tanimoto A, Mukai M, et al. Double- 62. McGahan JP, Lamba R, Fisher J, et al. Is segmen- ing of renal tumors with histopathologic correla-
phase helical CT of small renal parenchymal neo- tal enhancement inversion on enhanced biphasic tion. Invest Radiol 2012; 47:688–696

AJR:202, June 2014 1205

 Kang et al.

77. Kim S, Jain M, Harris AB, et al. T1 hyperintense logical types and grades by 3.0T diffusion- 88. Wang R, Wolf JS, Jr, Wood DP, Jr, Hig-
renal lesions: characterization with diffusion- weighted MRI. Eur J Radiol 2012; 81:3061–3066 gins EJ, Hafez KS. Accuracy of percutaneous
weighted MR imaging versus contrast-enhanced 83. Rosenkrantz AB, Niver BE, Fitzgerald EF, Babb core biopsy in management of small renal masses.
MR imaging. Radiology 2009; 251:796–807 JS, Chandarana H, Melamed J. Utility of the ap- Urology 2009; 73:586–590; discussion, 590–591
78. Zhang J, Tehrani YM, Wang L, Ishill NM, parent diffusion coefficient for distinguishing 89. DeLong W, Grignon DJ, Eberwein P, Shum DT,
Schwartz LH, Hricak H. Renal masses: character- clear cell renal cell carcinoma of low and high Wyatt JK. Sarcomatoid renal cell carcinoma: an
Downloaded from www.ajronline.org by 177.57.155.114 on 10/27/24 from IP address 177.57.155.114. Copyright ARRS. For personal use only; all rights reserved

ization with diffusion-weighted MR imaging—a nuclear grade. AJR 2010; 195:[web]W344–W351 immunohistochemical study of 18 cases. Arch
preliminary experience. Radiology 2008; 84. Slywotzky C, Maya M. Needle tract seeding of Pathol Lab Med 1993; 117:636–640
247:458–464 transitional cell carcinoma following fine-needle 90. Rheinheimer S, Stieltjes B, Schneider F, et al. In-
79. Sandrasegaran K, Sundaram CP, Ramaswamy R, aspiration of a renal mass. Abdom Imaging 1994; vestigation of renal lesions by diffusion-weighted
et al. Usefulness of diffusion-weighted imaging in 19:174–176 magnetic resonance imaging applying intravoxel
the evaluation of renal masses. AJR 2010; 85. Campbell SC, Novick AC, Herts B, et al. Prospec- incoherent motion-derived parameters: initial ex-
194:438–445 tive evaluation of fine needle aspiration of small, perience. Eur J Radiol 2012; 81:e310–e316
80. Wang H, Cheng L, Zhang X, et al. Renal cell carci- solid renal masses: accuracy and morbidity. Urol- 91. Lanzman RS, Robson PM, Sun MR, et al. Arterial
noma: diffusion-weighted MR imaging for subtype ogy 1997; 50:25–29 spin-labeling MR imaging of renal masses: cor-
differentiation at 3.0 T. Radiology 2010; 257:135–143 86. Smith EH. Complications of percutaneous ab- relation with histopathologic findings. Radiology
81. Cova M, Squillaci E, Stacul F, et al. Diffusion- dominal fine-needle biopsy. Radiology 1991; 2012; 265:799–808
weighted MRI in the evaluation of renal lesions: 178:253–258 92. Divgi CR, Uzzo RG, Gatsonis C, et al.
preliminary results. Br J Radiol 2004; 77:851–857 87. Volpe A, Mattar K, Finelli A, et al. Contemporary Positron emission tomography/computed tomog-
82. Yu X, Lin M, Ouyang H, Zhou C, Zhang H. Ap- results of percutaneous biopsy of 100 small renal raphy identification of clear cell renal cell carci-
plication of ADC measurement in characteriza- masses: a single center experience. J Urol 2008; noma: results from the REDECT trial. J Clin On-
tion of renal cell carcinomas with different patho- 180:2333–2337 col 2013; 31:187–194

1206 AJR:202, June 2014