Approach to the Incidental Approach to the Incidental

Solid Renal Mass Solid Renal Mass

Stuart G. Silverman, MD, FACR Stuart G. Silverman, MD, FACR
Professor of Radiology Disclosure of financial relationship with
Har ard Medical School
Harvard relevant commercial interest
Director, Abdominal Imaging
Lippincott, Williams, and Wilkins
and Intervention Philadelphia, PA – Book Royalties
Brigham and Women’s Hospital
Boston, MA

The Problem… Outline

• Renal masses are ubiquitous
• Imaging – vital in all
• Some benign masses cannot be
differentiated from RCC using aspects of management
imaging alone
• Biopsy – now an
• Small RCC behavior varies and accepted test
cannot be entirely predicted by
imaging or pathology features. • The JACR white paper
• Management is hence controversial

Differential Diagnosis
Consider…
Pseudotumors
Vascular abnormality
Inflammatory
Before Traumatic
considering…
Cystic or solid neoplasms

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 Management Recommendations Management Recommendations
Incidental Solid Renal Mass Incidental Solid
Provided there Renal Mass
is no detectable fat
Size Dx Recommend/Comment Size by CT Dx
or MRI…
MRI…
Recommend/Comment
Large RCC Surgery Rarely benign Large RCC Surgery Rarely benign
(> 3cm) (> 3cm)
Small RCC Surgery MRI/Biopsy if Small RCC Surgery MRI/Biopsy if
(1--3cm)
(1 hyperdense (1-3cm)
(1- hyperdense
Very small RCC Observe Use thin sections Very small RCC Observe Use thin sections
(< 1cm) AML until 1 cm (< 1cm) AML until 1 cm
Oncocytoma Oncocytoma
General Population General Population
Silverman SG et al, Radiology 2008 Silverman SG et al, Radiology 2008

RCC Containing Fat Cells Angiomyolipoma

• RCC containing fat cells is rare! The identification of fat cells in
• Most reported cases are of small
amounts of fat associated w/ Ca2+, and a noncalcified renal mass, in an
even rarer without Ca2+.
Fat Cells in RCC Mechanisms
adult, is virtually diagnostic of
Mature fat cells a benign renal angiomyolipoma
Lipid--laden macrophages (2/3 PRCC!)
Lipid
Osseous metaplasia
Cholesterol necrosis

Fat cells (FC) vs. AML vs RCC on MRI

Intracytoplasmic Lipid (ICL)
As renal cell carcinoma (clear
Kidney FC ICL cell type) may contain
RCC N* Y intracytoplasmic lipid, chemical
shift MRI should not be used
AML Y Y alone to discriminate renal
* Except case reports angiomyolipoma from renal cell
carcinoma.

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 Solid Masses may be benign Solid Masses may be benign
•Of 2,770 nephrectomies /NSS for Benign Tumors resected %
“solid” renal masses, 1977-
1977-2000 Oncocytoma 73
• 12.8% benign Angiomyolipoma 18
• Masses < 3 cm 25% benign Papillary adenoma* 4
• Masses < 2 cm 30% benign Not otherwise specified 4

• Masses < 1 cm 44% benign Metanephric adenoma 1

Frank et al J Urol 2003 *Papillary RCC <5mm Frank et al J Urol 2003

Oncocytoma vs Oncocytic
RCC: Immunocytochemistry
Onc OncRCC
Onc RCC
AE1/AE3 + +
EMA - +
RCC - +
Colloidal Fe - +*
S100A1 + -
*specific for Chromophobe RCC
Liu and Fanning Cancer Cytopath 2001
Li et al Histopathology 2007

Hyperdense + Enhancing MRI Features of Renal Masses

• RCC – typically papillary, or clear
cell sub
sub--type that has bled T1 T2 CE Dx
• Angiomyolipoma with minimal fat dark bright + RCC (CC type)
• Oncocytoma
• Lymphoma
d k
dark d k
dark + RCC (papillary)
( ill )
• Metanephric adenoma (rare) dark dark + AML with
• Leiomyoma (rare) minimal fat
• Metastases (rare)
Silverman et al RadioGraphics 2007

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AML with Minimal Fat AML with Minimal Fat
• Approximately 4-4-5% AML • Biopsy can be used to diagnose
contain little or no fat and are AML, particularly with the aid of
small, hyperdense, and immunocytochemistry
homogeneously enhancing AML RCC
masses MART1 + -
SMA + -
• Only 2% of RCC are hyperdense HMB--45
HMB + -
and homogeneously RCC - +
enhancing
Jinzaki et al Radiology 1997 Granter et al Cancer 1999

AML – Diagnostic Criteria AML with Minimal fat

• AMLs demonstrating no
• CT - ROI < -10 HU
fat have a characteristic
• MRI - fat suppression appearance (hyperdense
(not OOPS alone) and enhancing) that is not
common for RCC.
• Biopsy - +/-
+/- fat cells; thick
walled vessels, smooth • Biopsy can be used to
muscle (SMA and HMB45) biopsy them, and avoid
unnecessary surgery

Short (dark) T2 Masses AML w/ min fat vs RCC

• Sensitivity, specificity, and accuracy for combination of T2
• Hemorrhagic cyst SI ratio less than 0.9 and ([SII greater than 20% and T1 SI
ratio greater than 1.2] or arterial-
arterial-to
to--delayed enhancement
ratio greater than 1.5) were 73% (11 of 15), 99% (103 of 104),
• RCC (papillary type or and 96% (114 of 119), respectively, for differentiating AML
from RCC ((Sasiwimonphan p et al Radiologygy 2012))
clear cell RCC that bled)
• AML (%SI changed = 350) enhance more than CCRCC (%
SI change = 230) in CMP (Vargas et al Radiology 2012)
• AML (minimal fat, rich in
Problem is differentiating PRCC from AML, not all RCC,
smooth ms – spindle cells) and a probable diagnosis is not adequate in all cases.

• Leiomyoma of capsule Can MRI be used alone?

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 Management Recommendations Management Recommendations
Incidental Solid Renal Mass Incidental Solid Renal Mass
Size Dx Recommend/Comment Size Dx Recommend/Comment
Large RCC Surgery Rarely benign Large RCC Surgery Rarely benign
(> 3cm) or observe Consider biopsy CT or MRI at 3-6 mos, and 12 mos, then
(> 3cm)
yearly…
Small RCC Surgery MRI/Biopsy if Small RCC Surgery MRI/Biopsy if
(1--3cm)
(1 or observe hyperdense (1--3cm)
(1 hyperdense
Very small RCC Observe Use thin sections Very small RCC Observe Use thin sections
(< 1cm) AML until 1.5 cm (< 1cm) AML until 1 cm
Oncocytoma Oncocytoma
Limited life expectancy/Co-
expectancy/Co-morbidity General Population
Silverman SG et al, Radiology 2008 Silverman SG et al, Radiology 2008

Size and Growth…Solid

• The smaller the mass, the more
likely it is benign.
• W/U lesions that grow to 1 cm
• Growth is concerning but not
diagnostic of a malignancy.
• Lack of growth may be useful
indicator of a benign neoplasm, or
at least of benign behavior.
Silverman SG et al, Radiology 2008

Management flowchart… Management flowchart…

Berland LL et al, JACR 2010 Berland LL et al, JACR 2010

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Management flowchart…

Berland LL et al, JACR 2010

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