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Imaging Findings of Common Benign Renal Tumors in The Review Article | Genitourinary Imaging http://dx.doi.org/10.3348/kjr.2015.16.1.99 pISSN 1229-6929 · eISSN 2005-8330 Korean J Radiol 2015;16(1):99-113 Imaging Findings of Common Benign Renal Tumors in the Era of Small Renal Masses: Differential Diagnosis from Small Renal Cell Carcinoma – Current Status and Future Perspectives Sungmin Woo, MD1, Jeong Yeon Cho, MD1, 2 1Department of Radiology, Seoul National University College of Medicine, Seoul 110-744, Korea; 2Institute of Radiation Medicine and Kidney Research Institute, Seoul National University Medical Research Center, Seoul 110-744, Korea The prevalence of small renal masses (SRM) has risen, paralleling the increased usage of cross-sectional imaging. A large proportion of these SRMs are not malignant, and do not require invasive treatment such as nephrectomy. Therefore, differentation between early renal cell carcinoma (RCC) and benign SRM is critical to achieve proper management. This article reviews the radiological features of benign SRMs, with focus on two of the most common benign entities, angiomyolipoma and oncocytoma, in terms of their common imaging findings and differential features from RCC. Furthermore, the role of percutaneous biopsy is discussed as imaging is yet imperfect, therefore necessitating biopsy in certain circumstances to confirm the benignity of SRMs. Index terms: Small renal mass; Angiomyolipoma; Oncocytoma; Renal cell carcinoma INTRODUCTION instance, in a report by Frank et al. (6), it was found that 30% of tumors less than 2 cm in diameter were benign, The increased detection of small renal tumors has whereas 20% of those with a diameter greater than 4 cm paralleled the increased use of cross-sectional imaging (1). were benign. In a recent study of a series of 2675 tumors, The term small renal mass (SRM) has been used to refer to an increase of 16% in the odds of cancer was equated these tumors, usually defined as an enhancing tumor less with each centimeter increase in the size of the mass (7). than 4 cm in diameter (2). This has resulted in a 2% annual As a large proportion of SRMs are not malignant, they do increase in the incidence of renal cell carcinoma (RCC) over not require invasive treatment such as nephrectomy, and the past two decades with a migration to lower stages due follow-up imaging or treatment in the case of symptomatic to smaller size (2-4). Furthermore, it is not only RCC that presentations (i.e., renal artery embolization for bleeding have risen in incidence. Incidental SRMs represent both from angiomyolipoma [AML]) may suffice (8). Therefore, malignant and benign tumors (5). Especially, at smaller differentation between early RCC and benign SRM has SRM sizes, the proportion of benign SRM is higher. For become critical to achieve proper management. As there are Received June 24, 2014; accepted after revision October 28, 2014. a lack of symptoms and clinical characteristics to indicate Corresponding author: Jeong Yeon Cho, MD, Department of RCC in SRMs, differential diagnosis is highly dependent on Radiology, Seoul National University College of Medicine, 101 imaging characteristics. Daehak-ro, Jongno-gu, Seoul 110-744, Korea. In this review, we describe the radiological features of • Tel: (822) 2072-3074 • Fax: (822) 743-6385 • E-mail: [email protected] benign SRMs based on well-known findings in the literature This is an Open Access article distributed under the terms of and with incorporation of findings from recent reports. the Creative Commons Attribution Non-Commercial License We especially focused on two of the most common benign (http://creativecommons.org/licenses/by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in entities, AML and oncocytoma, in terms of their common any medium, provided the original work is properly cited. imaging findings and differential features from RCC as kjronline.org Korean J Radiol 16(1), Jan/Feb 2015 99 Woo et al. they are the most commonly encountered SRMs that could RCC and have reported promising results (Table 1). be mistaken as RCC. Detailed description of the imaging findings of less common types of benign SRMs and the US Findings of AML with Minimal Fat radiologic differentiation between subtypes of RCC are Traditionally, a hyperechoic renal mass on US without beyond the scope of this review. Finally, we introduce the features of a hypoechoic rim or intratumoral cysts is role that percutaneous biopsy may play in the era of SRMs. considered typical for AML when compared with RCC (12). However, when it comes to small AML with minimal fat, Imaging Findings of Common Benign there has been some controversy over the echogenicity of Small Renal Masses AMLs. Some have reported that they are homogeneously isoechoic (20, 21), whereas others found that they are Angiomyolipoma hyperechoic (19) or only slightly hyperechoic (22). Most Angiomyolipoma is one of the most common benign of these studies comparing the echogenicity of RCC and solid renal neoplasms (1). AML is composed of blood AML with minimal fat have been done on a subjective vessels, smooth muscle, and adipose tissue (9). It occurs basis and are not dedicated studies of SRMs. On the most often in the 4–6th decades, with preponderance in other hand, Lee et al. (23) reported that measuring the women (10). Radiologically, AML can be categorized into relative echogenicity of the lesion at a picture archiving the more classic AML and AML with minimal fat (11). and communication system monitor with the renal cortex Diagnosing the more classic AML is not difficult, as it and sinus fat referenced as 0 and 100%, respectively, was presents with gross fat, which is the pathologic hallmark useful in differentiating small AMLs from RCCs. While small of AML. Owing to this abundant fat component, AMLs AML with minimal fat (88%) demonstrated lesser relative show marked hyperechogenicity (usually as echogenic as echogenicity than classic AML (106.3%), it showed greater the renal sinus fat) on ultrasound (US) with reference to relative echogenicity compared with all subtypes (44.1%) the renal parenchyma (12, 13), and demonstrate areas of of RCC (Fig. 1). Although, further validation may be needed, unenhanced attenuation measuring < -10 Hounsfield units in our experience, we believe that comparing the relative (HU) on computed tomography (CT) (14). In addition, this echogenicity with that of sinus fat can be helpful in clinical fat content can be detected by using frequency selective fat practice. suppression and chemical shift fat suppression (15, 16) on magnetic resonance imaging (MRI). In cases of small classic CT Findings of AML with Minimal Fat AML, the typical radiologic findings of US, CT, and MRI are CT has been more meticulously studied with regard to all applicable. Yet, as the AML itself and the fat content small AML with minimal fat. One of the most representative is small, acquisition of thin sections (i.e., 1.5–3 mm) and findings of AML with minimal fat on CT is the extent of measuring the attenuation with small regions of interest hyperattenuation compared with the renal parenchyma. or even pixel values might be necessary to identify the fat It was found to be significantly more common in these content while avoiding partial volume averaging artifacts AMLs (53%) than in RCCs (13%) (24). This finding has also (14, 17, 18). been confirmed upon quantitative analysis with thresholds However, it may be difficult to differentiate AML with of > 38.5 HU and > 37 HU to differentiate small AML minimal fat from RCC (19) as they both contain too little with minimal fat from RCC and non-clear cell type RCC, fat to be directly detected on an unenhanced CT. This type respectively, resulting insensitivities and specificities up to of AML is typically reported to be small with an average 91.7% and 76.4%, respectively (Fig. 2) (25-27). A different diameter of 3 cm (19-21). As a result, these AMLs are approach that has been thoroughly examined is attenuation quite often misdiagnosed as RCC and are inadvertently measurement using histogram analysis on unenhanced CT. removed surgically (1). Generally, AML with minimal fat is Although earlier studies reported promising results with a pathologically diagnosed as an AML that contains no more high specificity (100%) and positive predictive value (100%) than 25% fat cells as visualized using high power field (28), further research by different investigators led to the microscopy (12). Yet, despite the poor lipid content, many realization that pixel histogram analysis cannot reliably investigators have tried to find methods to identify AML differentiate between AML with minimal fat and RCC, or at with minimal fat as well as radiologically distinguish it from least between AML with minimal fat and clear cell RCC (29, 30). 100 Korean J Radiol 16(1), Jan/Feb 2015 kjronline.org Imaging Findings of Benign Small Renal Masses Table 1. Imaging Findings of Small Angiomyolipoma with Minimal Fat Comparison Sensitivity Specificity Author (Reference) Imaging Finding Modality (Number/Mean Size [cm]) (%) (%) Hyperechogenicity on US AMLmf (15/2.7) Lee et al. (23) Relative echogenicity > 56.8% US 80 64 RCC (36/2.2) Hyperattenuation on precontrast CT High attenuation relative to adjacent AMLmf (19/2.8) Kim et al. (24) CT 53 87 renal parenchyma on unenhanced scan RCC (62/3.1) AMLmf (24/2.0) Woo et al. (25) Precontrast attenuation > 37 HU CT 92 76 NCCRCC (55/2.2) AMLmf (33/2.8) Yang et al. (26) Precontrast attenuation > 38.5 HU CT 84 82 RCC (102/3.7) AMLmf (48/NA) Kim et al. (27) High attenuation on unenhanced scan CT 60 88 RCC (359/NA) Low T2-weighted SI on MRI AMLmf (10/NA) Choi et al. (31) T2 SI ratio (tumor/spleen) < 92.5% MRI 90 90 RCC (57/NA) AMLmf (10/2.1) Sasiwimonphan et al.
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