Kim et al.

World Journal of Surgical Oncology (2016) 14:260

DOI 10.1186/s12957-016-1017-z

RESEARCH Open Access

Diagnostic accuracy of contrast-enhanced

computed tomography and contrast-
enhanced magnetic resonance imaging of
small renal masses in real practice:
sensitivity and specificity according to
subjective radiologic interpretation
Jae Heon Kim1, Hwa Yeon Sun1, Jiyoung Hwang2, Seong Sook Hong2, Yong Jin Cho3, Seung Whan Doo1,
Won Jae Yang1 and Yun Seob Song1*

Abstract
Background: The aim of this study was to investigate the diagnostic accuracy of contrast-enhanced computed
tomography (CT) and contrast-enhanced magnetic resonance imaging (MRI) of small renal masses in real practice.
Methods: Contrast-enhanced CT and MRI were performed between February 2008 and February 2013 on 68
patients who had suspected small (≤4 cm) renal cell carcinoma (RCC) based on ultrasonographic measurements.
CT and MRI radiographs were reviewed, and the findings of small renal masses were re-categorized into five
dichotomized scales by the same two radiologists who had interpreted the original images. Receiver operating
characteristics curve analysis was performed, and sensitivity and specificity were determined.
Results: Among the 68 patients, 60 (88.2 %) had RCC and eight had benign disease. The diagnostic accuracy
rates of contrast-enhanced CT and MRI were 79.41 and 88.23 %, respectively. Diagnostic accuracy was greater
when using contrast-enhanced MRI because too many masses (67.6 %) were characterized as “4 (probably solid
cancer) or 5 (definitely solid cancer).” The sensitivity of contrast-enhanced CT and MRI for predicting RCC were 79.
7 and 88.1 %, respectively. The specificities of contrast-enhanced CT and MRI for predicting RCC were 44.4 and
33.3 %, respectively. Fourteen diagnoses (20.5 %) were missed or inconsistent compared with the final
pathological diagnoses. One appropriate nephroureterectomy and five unnecessary percutaneous biopsies were
performed for RCC. Seven unnecessary partial nephrectomies were performed for benign disease.
Conclusions: Although contrast-enhanced CT and MRI showed high sensitivity for detecting small renal masses,
specificity remained low.
Keywords: Renal cell carcinoma, Magnetic resonance imaging, Computed tomography

* Correspondence: [email protected]
1
Department of Urology, Soonchunhyang University Hospital,
Soonchunhyang University College of Medicine, 59, Daesagwan-ro,
Yongsan-gu, Seoul 140-743, Republic of Korea
Full list of author information is available at the end of the article

© 2016 The Author(s). Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Kim et al. World Journal of Surgical Oncology (2016) 14:260 Page 2 of 8

Background Methods
Radiological diagnostic accuracy has evolved for pa- Contrast-enhanced CT and MRI were initially performed
tients with renal cell carcinoma (RCC) over the last in 77 patients with potential small (≤4 cm) RCC, as sug-
two decades, such that small masses can be identified gested by ultrasonography. Imaging was performed at
more easily [1]. These developments have led to a Soonchunhyang University Hospital between February
greater number of RCC diagnoses. The trends can be 2008 and February 2013. This study was approved by
largely explained by the development of methods, such the Soonchunhyang University Hospital International
as contrast-enhanced computed tomography (CT) and Review Board.
contrast-enhanced magnetic resonance imaging (MRI), Nine of the 77 patients refused surgical treatment.
that enable more accurate diagnosis and more frequent Those undergoing cyto-reductive nephrectomies and
diagnosis of small masses (≤4 cm, based on abdominal those with documented metastatic disease prior to surgi-
imaging) [2]. With an increased use of such cross- cal intervention were excluded. Such patients were ex-
sectional imaging techniques, the majority of neoplasms cluded because most were known to have conventional
(up to 80 %) are now discovered incidentally [3, 4]. RCC. Thus, 68 patients were available for the data ana-
CT has traditionally been regarded as the imaging lysis. Contrast-enhanced CT and MRI were performed
modality of choice to evaluate RCC owing to its fast ac- on small masses (≤4 cm in diameter), as detected by
quisition time and the excellent anatomic detail pro- conventional CT or abdominal ultrasonography.
vided [3]. However, MRI has gained popularity for The small renal masses were routinely evaluated using
evaluating and treating RCC. MRI offers advantages, contrast-enhanced CT and contrast-enhanced MRI in
such as lack of ionizing radiation, compared to CT. corticomedullary, venogenic, and nephrographic phases.
More importantly, MRI can detect and classify patholo- Two experienced urologic radiologists (HSS and JYH),
gies, which makes MRI advantageous for classifying who made the original interpretations, conducted a
and specifying treatment outcomes, including specify- retrospective review of the contrast-enhanced CT and
ing useful target therapies [3, 5]. MRI scans.
Most RCCs are “clear-cell” RCCs, which makes this Contrast-enhanced computed tomography was per-
histological subtype particularly important with respect formed in unenhanced, corticomedullary, and nephro-
to prognosis [1, 2]. While clear-cell RCC is the most graphic phases, using 64-channel scanners (Sensation
prevalent among the various categories, RCC is a hetero- 64; Siemens Medical Solutions, Erlangen, Germany).
geneous disease that includes a large number of subtypes Unenhanced images were obtained, and then, an intra-
that differ in their histopathological features, gene ex- venous contrast agent (Omnipaque 320 [iohexol, GE
pression patterns, and clinical behavior. Several studies Medical System Milwaukee, WI, USA; or Iomeron 350
have demonstrated the diagnostic value of contrast- [iomeprol], Bracco, Milano, Italy) was injected using a
enhanced CT or contrast-enhanced MRI for predicting power injector at a dose of 2 mL/kg of body weight and
RCC histological subtypes [6, 7]. a rate of 3.0 mL/s up to a maximum of 150 mL. The
More specifically, contrast-enhanced MRI has been scan delay of corticomedullary phase scanning was de-
described as being particularly useful for diagnosing termined by an automatic bolus triggering technique of
small renal masses [8]. The most important issue with MDCTs; scanning started when the CT number of a
such small renal masses is judging whether they are region of interest (ROI) in the abdominal aorta
malignant. The majority of solid masses are malignant reached 100 HU. The scan delay for nephrographic
(>80 %), but smaller masses have a greater tendency phase scanning was 180 s. The scanning parameters
to be benign types, such as oncocytomas or angio- were as follows: X-ray tube voltage, 120 kV; tube
myolipomas. Specifically, up to 25 % of small solid current, 100–250 mA, which was determined by an
renal lesions (<4 cm) are benign [9]. Notably, the dis- automatic dose modulation technique; and slice thick-
tinction between a benign and a malignant mass is ness/reconstruction interval, 5 mm/5 mm for unen-
difficult to make for small cystic lesions (e.g., it is dif- hanced and 3 mm/3 mm for corticomedullary phase
ficult to distinguish between multi-locular cysts and scanning and early excretory phase scanning.
cystic RCC) [10]. MR imaging was performed using a 3.0-T unit (Dis-
Few studies have investigated the diagnostic accuracy covery MR750w; GEHealthcare, Milwaukee, WI, USA)
of contrast-enhanced CT and contrast-enhanced MRI in with a phased-array coil. After localizer images were
real practice, particularly as related to treatment deci- acquired, the following sequences were obtained: (a)
sions. Thus, the overall aim of our study was to evaluate coronal T2-weighted single-shot fast spin echo without
the diagnostic accuracy of the two imaging modalities fat saturation (repetition time msec/echo time msec,
and to investigate the detailed disease states of the mis- 1500/90; 90° flip angle; bandwidth, ±83 kHz; field of
diagnosed small masses. view, 40 cm; section thickness, 5 mm; gap, 0.5 mm;
Kim et al. World Journal of Surgical Oncology (2016) 14:260 Page 3 of 8

320 × 288 matrix); (b) axial T2-weighted single-shot radiological images and to the final pathological findings.
fast spin echo without fat saturation (repetition time Ratings of 1 to 2 were labeled “non-cancer,” whereas
msec/echo time msec, 1500/80; 90° flip angle; band- those of 3 to 5 were labeled “cancer.”
width, ±83 kHz; field of view, 34 cm; section thickness, Diagnostic accuracy was defined by whether masses
5 mm; gap, 0.5 mm; 384 × 256 matrix); (c) axial volu- were categorized as “4 (probably solid RCC) or 5
metric 3D fat fraction sequence, called iterative de- (definitely solid RCC)” or “3 (indeterminate RCC)”
composition of water and fat with echo asymmetry and tumors. The decision to use these categories was
least square estimation (IDEAL-IQ; GE healthcare) supported by the tendency of urologists to most
(repetition time of 6.6 msec and six different echo commonly label specific diseases as either “4 (prob-
times that ranged from 1.6 to 9.8 msec; 15° flip angle; ably solid RCC) and 5 (definitely solid RCC)” or “3
bandwidth, ±142 kHz; field of view, 34 cm; section (indeterminate RCC)” tumors.
thickness, 4.6 mm; gap, 2.3 mm; 272 × 224 matrix); and Accuracy including sensitivity, specificity, and posi-
(d) three-dimensional fat-saturated T1-weighted GRE tive and negative predictive values was analyzed using
images (5.9/1.1; 15° flip angle; section thickness, receiver operating characteristic (ROC) curve. STATA
4.6 mm; bandwidth, ±142 kHz; field of view, 34 cm; version 14 software (Stata Corp LP, College Station, TX,
320 × 224 matrix) obtained before and after adminis- USA) was used for statistical analysis, and graphs were
tration of an intravenous bolus of 0.1 mmol/kg of generated by MedCalc—version 13.0.4. Significant dif-
gadoteridol (Prohance; Bracco, Milano, Italy) at a rate ferences were defined by P < 0.05.
of 1.5–2.0 mL/s, and followed by a 20-mL saline flush.
Contrast agent-enhanced images were acquired in the
corticomedullary and nephrographic phases using an Results
automatic bolus triggering technique. The nephro- Among the 68 patients, 60 (88.2 %) had RCC and eight
graphic phase was initiated 30–40 s after the cortico- had benign disease (Table 1). Among those with RCC,
medullary phase. 51 (75.0 %) had clear-cell RCC and nine (13.2 %) had
An apparent diffusion coefficient (ADC) map was ob- papillary or choromophobe RCC. Among the patients
tained at each slice position. The ADC was measured with benign lesions, four (5.88 %) had oncocytoma and
in an approximately 1-cm region of interest within the three had angiomyolipoma, multi-locular cysts, or papil-
normal renal parenchyma. ADC values in normal renal lary tubule-adenoma.
parenchyma ranged from 1.72 × 10−3 mm2 s−1 to 2.65 × The mean patient age was 63.1 years. Forty-seven pa-
10−3 mm2 s−1. tients were male and 21 were female. All RCCs were in
For visual assessment and to provide quantitative diag- the T1a stage. All were solid or cystic masses, with no
nostic criteria with the abovementioned techniques, a 5- renal capsule or vessel involvement.
point scale was used: 1 indicates definitely fluid or
definitely not cancer: a benign simple cyst or water Table 1 Characteristics of the study subjects (n = 68)
density without enhancement; 2 indicates probably fluid Age 63.1
or probably not cancer: a benign cyst of thin septa with
Male 47 (69.11)
a few hairline septa. For solid lesions, uniformly high-
density cysts with clear margins and without enhance- Female 21 (30.88)
ment can be present; 3 represents an indeterminate risk Method of pathologic confirmation
of cancer: measurable enhanced wall or septa with ir- Percutaneous biopsy 4 (5.88)
regular thickening and smooth wall; 4 indicates probable Partial nephrectomy 42 (61.7)
cystic or solid cancer: irregular marginated cystic masses Radical nephrectomy 20 (29.4)
with enhanced soft-tissue components; and finally, 5 in-
RCC 60 (88.2)
dicates definite cystic solid cancer: clear cystic or solid
malignant masses with or without calcification and with Clear-cell RCC 51 (75.0)
irregular vascularity. There is a prominent gap in the en- Papillary or chromophobe RCC 9 (13.2)
hancement pattern between the mass and the cortex Metastatic adenocarcinoma 1 (1.47)
during the corticomedullary phase. Benign mass 7 (10.2)
The interpretations were re-categorized using the 5- Oncocytoma 4 (5.88)
point scale (“1 (definitely fluid or definitely not cancer),
Angiomyolipoma 1 (1.47)
2 (probably fluid or probably not cancer), 3 (indetermin-
ate risk of cancer), 4 (probably solid cancer), or 5 (defin- Multi-locular cyst 1 (1.47)
itely solid cancer)”) by the two radiologists and by an Tubulo-papillary adenoma 1 (1.47)
attending urologic oncologist who was blinded to the n number, RCC renal cell cancer
Kim et al. World Journal of Surgical Oncology (2016) 14:260 Page 4 of 8

Table 2 Diagnostic accuracies of CT and MRI (n = 68)

Radiologic interpretation “4 (probably solid RCC) and 5 (definitely solid RCC)” “3 (indeterminate RCC)” Total
CT 33 (48.5) 21 (30.8) 54 (79.41)
MRI 46 (67.6) 14 (20.58) 60 (88.23)
a
Radiologic interpretation Sensitivity Specificity AUC SE 95 % CIb
CT 79.7 44.4 0.621 0.0917 0.495 to 0.736
MRI 88.1 33.3 0.607 0.0860 0.481 to 0.724
n number, CT computed tomography, MRI magnetic resonance imaging
a
Binomia exact
b
Binomial exact

The diagnostic accuracies of contrast-enhanced CT oncocytoma, one case of acute myeloid leukemia, one
and MRI were 79.41 and 88.23 %, respectively (Table 2). case of metastatic adenocarcinoma, and one multi-
A tendency was observed for masses to be diagnosed as locular cyst.
“4 (probably solid RCC) and 5 (definitely solid RCC)” at
a higher rate by contrast-enhanced MRI than by Discussion
contrast-enhanced CT. The contrast-enhanced MRI The role of imaging studies when deciding the treat-
characterization rate of the “4 (probably solid RCC) and ment modality for renal masses is extremely important.
5 (definitely solid RCC)” state was 67.6 % (Table 2). The subjective visual impression by a radiologist has a
The sensitivities for contrast-enhanced CT and MRI for known critical role in differentiating a simple cyst from
the prediction of RCC were 79.7 and 88.1 %, respect- a solid mass [11, 12]. Moreover, the precision of this
ively. The specificities for contrast-enhanced CT and subjective impression for detecting a mass is improved
MRI were 44.4 and 33.3 %, respectively (Fig. 1). by the use of contrast-enhanced CT or contrast-
The diagnostic advantage of contrast-enhanced MRI is enhanced MRI [13].
described in detail in Table 3. The diagnoses of 14 pa- However, the real role of the subjective impression
tients were upgraded from “3 (indeterminate RCC)” to based on contrast-enhanced CT or contrast-enhanced
“4 (probably solid RCC) or 5 (definitely solid RCC)” in MRI has not been fully evaluated, particularly when de-
five patients (7.35 %) (Table 3). tecting small renal masses. Most studies have demon-
Fourteen cases were missed or inconsistently diag- strated a high accuracy of contrast-enhanced CT and
nosed, compared with the final pathological diagnoses MRI through retrospective analyses. However, most
(20.5 % of all cases) (Table 4). One appropriate urologists make clinical decisions based on the subject-
nephroureterectomy and two unnecessary percutaneous ive impression of a radiologist.
biopsies were performed for clear RCCs. Three unneces- The greatest pitfalls of clinical studies regarding the
sary percutaneous biopsies were performed for papillary diagnostic accuracy of small renal masses include the
or choromophobe RCCs. Seven unnecessary partial disparity of viewpoints between urologists and radiolo-
nephrectomies were performed in patients with benign gists. Radiologists generally focus on the accuracy of
disease. Those seven cases included three cases of radiologic imaging according to their final pathological

Fig. 1 Sensitivities and specificities of dynamic computed tomography and dynamic magnetic resonance imaging for prediction of the final diagnosis
Kim et al. World Journal of Surgical Oncology (2016) 14:260 Page 5 of 8

Table 3 Advantage of diagnostic upgrading by MRI (n = 14)

Final diagnosis N (% for total N) CT interpretation MRI interpretation Treatment
Clear RCC 13 (19.11)
8 (11.76) “3 (indeterminate RCC)” “4 (probably solid RCC) or 5 (definitely solid RCC)” Partial Nx
5 (7.35) “3 (indeterminate RCC)” “4 (probably solid RCC) or 5 (definitely solid RCC)” Partial Nx
Papillary RCC 1 (1.47) “3 (indeterminate RCC)” “4 (probably solid RCC) or 5 (definitely solid RCC)” Partial Nx
Total 14 (20.5)
N number, CT computed tomography, MRI magnetic resonance imaging, RCC renal cell cancer, Nx nephrectomy

reports, and urologists generally only focus on the suc- Diagnostic and staging accuracy for renal masses has
cess rate of surgery. Hence, there have been few studies been investigated for multiple imaging modalities, in-
on the real value of radiologic imaging in the establish- cluding ultrasound sonography, CT, and MRI [13]. Al-
ment of a treatment plan or regarding treatment with though some reports have investigated the diagnostic
surgery or other procedures without considering the real efficiency of contrast-enhanced MRI for the detection
diagnosis. The current study, although handicapped by of small clear-cell RCC [8], small renal masses have
small inclusion numbers, addresses this issue. often been neglected. Few studies have assessed the

Table 4 Diagnoses missed by CT and MRI (n = 14)

Final diagnosis Clinical N (% for Shape of CT interpretation MRI interpretation Treatment
impression total N) mass
Clear RCC TCC 3 (4.41) Case #1 Solid “3 (indeterminate “3 (indeterminate Nephroureterectomy
RCC),” RCC),” “4 (probably
“4 (probably solid solid TCC)”
TCC)”
AML Case #2 Solid “4 (probably solid “3 (indeterminate Percutaneous biopsy
AML)” RCC),” “4 (probably and partial Nx
solid AML)”
Complicated Case #3 Cystic “2 (probably fluid)” “2 (probably fluid),” Percutaneous biopsy
cyst “3 (indeterminate and partial Nx
RCC)”
Papillary or chromophobe Complicated 3 (4.41) Case #1 Cystic “2 (probably fluid)” “2 (probably fluid),” Percutaneous biopsy
RCC cyst “3 (indeterminate and partial Nx
RCC)”
Complicated Case #2 Cystic “2 (probably fluid)” “2 (probably fluid),” Percutaneous biopsy
cyst “3 (indeterminate and partial Nx
RCC)”
AML Case #3 Cystic “3 (indeterminate “4 (probably solid Percutaneous biopsy
RCC)” RCC)” and partial Nx
Angiomyolipoma RCC 1 (1.47) Case #1 Solid “3 (indeterminate “4 (probably solid Partial Nx
RCC)” RCC)"
Oncocytoma RCC 4 (5.88) Case #1 Solid “3 (indeterminate “4 (probably solid Partial Nx
RCC)” RCC)”
RCC Case #2 Solid “3 (indeterminate “4 (probably solid Partial Nx
RCC)” RCC)”
RCC Case #3 Solid “4 (probably solid “3 (indeterminate Partial Nx
AML)” RCC)”
RCC Case #4 Solid “4 (probably solid “3 (indeterminate Partial Nx
AML)” RCC)”
Adenocarcinoma RCC 1 (1.47) Case #1 Cystic “3 (indeterminate “3 (indeterminate Partial Nx
RCC)” RCC)”
Multi-locular cyst RCC 1 (1.47) Case #1 Cystic “4 (probably solid “3 (indeterminate Partial Nx
RCC)” RCC)”
Total 14 (20.58 %)
N number, CT computed tomography, MRI magnetic resonance imaging, RCC renal cell cancer, TCC transitional cell carcinoma, AML angiolipoma, Nx nephrectomy
Kim et al. World Journal of Surgical Oncology (2016) 14:260 Page 6 of 8

correlation between a diagnosis of small renal mass and contrast-enhanced CT and contrast-enhanced MRI, which
treatment strategy [14, 15]. This is the first report that can help clinicians make prompt decisions.
attempts to clarify the clinical value of contrast- The CT findings including enhancement pattern has
enhanced CT and contrast-enhanced MRI in establish- shown significant association with histological subtypes
ing a treatment strategy for small renal masses. of renal cell cancer [19, 20, 24, 25]. In CT findings,
CT has been the traditional imaging modality of clear-cell RCC tends to contain suspected necrosis with
choice for detecting RCC and for RCC staging work-up. heterogenous enhancement pattern compared with
CT provides excellent anatomical detail, allowing for chromophobe and papillary RCCs [19, 25]. The imaging
complex three-dimensional reconstruction of a renal characteristics of CT predict the clear-cell RCC with an
tumor and the vascular anatomy [3, 5]. However, a pitfall accuracy of 72 %, but shows lower accuracy in small
of CT when evaluating a renal mass is that it cannot de- renal tumors ≤5 cm [20].
tect small renal masses [16, 17]. An artificial alteration In our analysis, CT or MRI findings did not reveal dif-
for CT when assessing renal lesions, particularly small ferent necrosis patterns. Because most tumors were
lesions, is a “partial volume artifact,” which often results small with a round pattern, it was difficult to analyze
in an incorrect diagnosis [18]. pattern nodularity, tumor shape, or round margins.
MRI has grown in popularity owing to its advantages RCC subtyping using contrast-enhanced MRI has
in the histological characterization of masses [19, 20]. been investigated with excellent results [6–8]. We
MRI offers the advantages of excellent non-ionizing radi- found previously that signal intensity changes during
ation exposure and exquisite tissue characterization the corticomedullary phase are the most effective
compared with CT. In particular, MRI allows for excel- means of distinguishing small clear-cell from papillary
lent characterization of cystic and solid masses owing to cell RCC [8].
its ability to detect hemorrhage, intracellular fat, and Similar to small solid renal masses, small renal cysts
intra-cystic architecture using various MRI techniques also have complexities with regard to RCC detection
including diffusion-weighted images or arterial spin la- [26]. A popular CT-based classification system to deter-
beling or MR spectroscopy [3]. CT has proven limita- mine the malignant potential of a cystic kidney lesion is
tions for detecting RCC [10, 16, 17]. the Bosniak classification system, which classifies cysts
Use of MRI for renal imaging has traditionally been from benign or simple cyst to malignant RCCs [27].
limited to cases in which diagnosis by ultrasonog- Clinically challenging complex cystic lesions are Bosniak
raphy or CT was inconclusive and cases in which the IIF and Bosniak III, which could reveal malignancy up to
presence or absence of tumor thrombi was being in- 50 % [28]. CT has traditionally been regarded as the mo-
vestigated [21]. MRI has replaced venacavography as dality of choice for evaluating renal cysts [27, 29]. Israel
the gold standard when evaluating extensions of et al. [27] reported the superiority of MRI to CT regard-
renal tumors into the inferior vena cava. MRI is con- ing sensitivity in their retrospective review of 69 cystic
sidered superior to spiral CT for this application, renal lesions. Although they reported the greater sensi-
with a sensitivity of 100 % and a specificity of ap- tivity of MRI in complicated cystic lesions, they did not
proximately 90 % [22]. investigate about the specificity of CT or MRI.
The diagnostic abilities of CT and MRI to predict the Our study revealed that the sensitivities of subjective
pathologic diagnosis have been evaluated. Most studies impressions for contrast-enhanced CT and MRI to pre-
have focused on distinguishing RCC from benign entities dict RCC were 79.7 and 88.1 %, respectively, and the
in clear cells. This is an important issue, as clear-cell specificities of contrast-enhanced CT and MRI for pre-
RCC has different characteristics than do other types of dicting RCC were 44.4 and 33.3 %, respectively. These
RCC and the prognosis for clear-cell RCC is usually results indicate that the accuracy of subjective impres-
worse than for other types of RCC. sion for contrast-enhanced CT and MRI is not as high
Contrast-enhanced MRI has been used to detect small as previously reported, which could result in either over-
renal masses and to predict RCC pathological subtypes or under-treatment. In our study, two cases of papillary
[8]. Diverse MRI techniques, such as diffusion-weighted RCC were misdiagnosed as complicated cysts by both
imaging, have enhanced the role of MRI in detecting contrast-enhanced CT and MRI, suggesting a challenge
RCC among small renal masses [10]. However, these to reach a clear diagnosis for small renal cystic masses.
techniques require a ROI, which can vary between and In our study, although the sensitivity of diagnostic ac-
within observers, based on the size and position of the curacy for contrast-enhanced MRI was higher than that
ROI [23]. However, those reports are based on thorough for contrast-enhanced CT, specificity was low for both
retrospective review and analysis of images, and this is imaging modalities. This indicates that a serious RCC le-
not a realistic situation in real practice. Hence, we fo- sion could be missed by both imaging modalities. In
cused on the role of subjective interpretation of addition, more aggressive treatment modalities were
Kim et al. World Journal of Surgical Oncology (2016) 14:260 Page 7 of 8

suggested for benign masses in some cases. Three un- Soonchunhyang University Hospital, Soonchunhyang University College of
necessary percutaneous biopsies and seven unnecessary Medicine, Seoul, Republic of Korea. 3Department of Family Medicine,
Soonchunhyang University Cheonan Hospital, Soonchunhyang University
partial nephrectomies were performed. Thus, further College of Medicine, Cheonan, Republic of Korea.
studies are needed to investigate the real role of
contrast-enhanced CT and MRI in predicting the patho- Received: 17 December 2015 Accepted: 4 October 2016

logic diagnosis of such small renal masses. Advanced

contrast-enhanced MRI techniques may be useful for
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