G e n i t o u r i n a r y I m a g i n g • R ev i ew

Stakhovskyi et al.
Treatment Planning for Small Renal Masses

Genitourinary Imaging
Review

Small Renal Mass: What the

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Urologist Needs to Know

FOCUS ON:

for Treatment Planning and

Assessment of Treatment Results
Oleksandr Stakhovskyi1 OBJECTIVE. Small renal mass is a new distinct clinical entity. Detection of these tumors
Stanley A. Yap has increased with increased use of imaging.
Michael Leveridge CONCLUSION. We know that a proportion of these tumors are not renal cell carcinoma,
Nathan Lawrentschuk and imaging-guided biopsy is being increasingly used for treatment planning. The objectives
Michael A. S. Jewett of this review are to provide an update on our current understanding of the biology of small
renal masses and to review approaches to the diagnosis and treatment of these lesions.
Stakhovskyi O, Yap SA, Leveridge M,
Lawrentchuk N, Jewett MAS

Keywords: active surveillance of small renal mass,
kidney cancer, kidney imaging, kidney neoplasms, small
renal mass
DOI:10.2214/AJR.10.6336
Received December 9, 2010; accepted after revision
December 19, 2010.
1
All authors: Division of Urology, Departments of Surgery
and of Surgical Oncology, Princess Margaret Hospital
and the University Health Network, University of
Toronto, 610 University Ave, 3-124, Toronto, Ontario M5G
2C4, Canada. Address correspondence to
M. A. S. Jewett (m.jewett@utoronto.ca).
AJR 2011; 196:1267–1273
0361–803X/11/1966–1267
© American Roentgen Ray Society
K
idney cancer is the third most
common urologic malignancy
and represents 4% of all malig-
nancies. In the United States in
2010, an estimated 58,000 new cases of renal
cell carcinoma (RCC) were diagnosed, with
13,000 deaths [1]. A 2% annual increase in
the incidence of RCC has occurred over the
past two decades, largely because of the in-
creased utilization of imaging [2, 3]. The
majority of these tumors are small, so there
has been a stage migration in incident cases
of RCC [4]. However, these lesions represent
both malignant and benign tumors (e.g., on-
cocytoma and angiomyolipoma) [5]. The
term “small renal mass” has been introduced
for these small tumors. Small renal masses
have been defined as enhancing tumors less
than 4 cm in diameter [3].
Controversies have developed along with
the increasing incidence of small renal mass-
es—should they be biopsied, watched, or
treated? Most small renal masses are diag-
nosed in the sixth or seventh decade of life,
when there is increasing comorbidity [6].
Many small renal masses are not RCCs but
benign lesions (30% of tumors < 2 cm in di-
ameter and 20% of those > 4 cm in diameter)
[7]. In a large series of 2675 tumors, a 16%
increase in the odds of cancer was calculat-
ed for each centimeter increase in tumor size
[8]. Many small renal masses, even biopsy-
proven malignant ones, may be relatively in-
dolent, even if malignant [9, 10]. A pooled
analysis of small renal masses (mean diam-
eter, 2.6 cm) managed by observation found
a mean growth rate of 0.28 cm/year over 34
months [11]. Interestingly, size at presenta-
tion did not predict the growth rate.
If a small renal mass is an RCC, it is TNM
category T1a [12, 13]. Such masses have an
excellent prognosis with treatment, so it is
not surprising that, despite earlier diagnosis
and treatment, reported overall RCC-specific
mortality has not decreased in recent years.
Currently, pretreatment pathologic confir-
mation of RCC requires a core needle biop-
sy. Traditionally, needle biopsy was not done
because of concerns about safety, tumor
seeding, and accuracy. Importantly, the idea
that biopsy results rarely change manage-
ment plans reduced its utility, but as patho-
logic assessment has improved, this idea is
being challenged [9, 10, 14].
Small renal masses that are RCCs include
the major histologic variants: clear cell RCCs
(80–90% of RCCs), papillary RCCs (10–
15% of RCCs), and chromophobe RCCs (4–
5% of RCCs) (WHO 2004) [15]. Patard et al.
[16] found a trend toward better prognosis for
patients with chromophobe RCCs compared
with papillary and clear cell RCCs. Two ma-
jor subtypes of papillary RCCs exist: type 1
(small cells and pale cytoplasms) and type
2 (large cells and eosinophilic cytoplasms).
Pignot et al. [17] demonstrated the prognos-
tic significance of these types and reported
worse outcomes in patients with type 2 pap-
illary RCCs compared with type 1 papillary
RCCs. Patients presenting with type 2 pap-
illary RCCs have mostly high-grade tumors
with an increased risk of metastasis. The his-
tologic Fuhrman grading system remains an
independent prognostic factor for RCC [15].

AJR:196, June 2011 1267

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Stakhovskyi et al.

Imaging Characteristics of Small
Renal Masses
Ultrasound
CT is the primary imaging method used in
the characterization of renal masses, but ultra-
sound remains useful [18]. Ultrasound is the
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pecially in patients with antecedent renal
dysfunction) may lead to increased use of
contrast-enhanced ultrasound [24].
CT
Advances in CT technology have retained
tive of AML [35]. Compared with RCC, fat-
poor AML has been shown to be more ho-
mogeneously enhancing and to have a de-
layed washout of contrast agent [35].
MRI

most commonly used diagnostic technique
and may be used in subsequent surveillance
without radiation burden. Ultrasound has par-
ticular utility in the characterization of cystic
masses, including hyperdense cysts that may
pose a diagnostic challenge to CT. Ultrasound
is rarely, if ever, the only method used to char-
acterize a mass. Compared with CT in a study
of 189 small renal masses in 21 patients with
von Hippel–Lindau syndrome, ultrasound
failed to identify 65 CT visible lesions, and
only one lesion was missed by CT that was
identified by ultrasound [19]. The sensitivity
of ultrasound decreases with tumor size, such
that at 1 cm, ultrasound was only able to iden-
tify 20% of masses, compared with 76% iden-
tified by CT. The sensitivity of ultrasound im-
proved to 70% for tumors of 2 cm, but was
still inferior to that of CT (95%). The detec-
tion rate was not equal until the lesions mea-
sured 3.5 cm. Ultrasound is operator depen-
dent, and interpretation is affected by body
habitus and overlying anatomy. Assessment
of the retroperitoneum and renal vasculature
is limited, which is important in tumor stag-
ing; both expert opinion and published guide-
lines therefore support the use of cross-sec-
tional imaging with CT or MRI in the workup
of a renal tumor [20, 21].
Contrast-enhanced ultrasound with intra-
vascular microbubble contrast agents can
assess enhancement of vascular elements
within tissue. In 29 patients undergoing ne-
phrectomy, contrast-enhanced ultrasound was
able to identify increased flow in all 29 cas-
es, including four cases of classically hypo-
vascular papillary RCC, whereas CT failed
to show enhancement in five cases; the au-
thors of that study concluded that contrast-
enhanced ultrasound is more sensitive than
CT in the investigation of hypovascular tu-
mors [22]. A detection specificity of 96.4%
and a sensitivity of 77.3% were reported for
contrast-enhanced ultrasound in a series of
renal masses smaller than 5 cm that includ-
ed a large proportion of benign lesions [23].
The role of contrast-enhanced ultrasound in
the investigation and management of small
renal masses and RCC is in evolution (Fig.
1). Recent concern about the effects of ion-
izing radiation from CT and the potential
toxicity of CT and MRI contrast agents (es-
its status as the reference standard in the rec- MRI has typically been the “problem-
ommended assessment of small renal mass- solving” method for the assessment of renal
es [20, 21, 25]. Evidence of vascularization masses (e.g., for resolving inconclusive find-
with contrast enhancement is the key to de- ings on ultrasound or CT) or for patients with
fining a small renal mass as a solid tumor. contraindications to the use of iodinated con-
Delayed scans provide evaluation of the uro- trast media [36] (Fig. 2). The emerging role
thelium when there is suspicion that the mass of active surveillance of small renal masses
may be urothelial or invasive. Although no requires repeated follow-up imaging, mak-
universal protocol exists, the nephrograph- ing MRI with its lack of ionizing radiation ap-
ic phase at approximately 100 seconds af- pealing [18]. As with CT, differentiation of the
ter contrast administration assesses the re- different RCC subtypes with MRI has proven
nal parenchyma [26, 27] (Fig. 2). Contrast to be difficult [37, 38]. As with CT, AMLs
enhancement is commonly defined as an in- classically have obvious fat present, where-
crease of 10 HU or more between the unen- as fat-poor AMLs may not, because they are
hanced and contrast-enhanced images; some typically hypointense on T2-weighted imag-
authors contend, however, that enhancement ing [38]. The presence of high-intensity fluid
of 10–20 HU should be considered indeter- on T2 images or the lack of enhancement dif-
minate [28]. Pseudoenhancement of small ferentiates cysts from solid masses. Because
renal masses can occur as a result of vivid there is no ready analog to Hounsfield units,
enhancement of surrounding normal renal the percentage of enhancement over baseline
parenchyma and should be considered, espe- is used. Typically, cysts should enhance by ap-
cially with endophytic masses. Care must be
taken in the measurement of enhancement in
heterogeneous masses; the same area of the
mass must be quantified at each time point to
reliably determine enhancement. High con-
cordance is expected between radiologists in
defining a mass as enhancing or nonenhanc-
ing, when standard definitions are used [29].
Image characterization of histologic pro-
files has proven to be difficult. Conventional
clear cell RCCs are hypervascular in 50–
90% of cases, compared with single-digit
percentages for papillary and chromophobe
RCCs. Necrosis is far more common in clear
cell RCCs [30]. The presence of calcification
has not reliably been shown to represent one
subtype over another, although it has been
seen to predict malignancy with a 98% posi-
tive predictive value [30, 31]. There are no
reliable criteria to distinguish oncocytomas
from RCCs [32] (Fig. 3). The classic central
stellate scar, which was long thought to rep-
resent oncocytoma, is present in less than
half of cases [33]. On the other hand, macro-
scopic fat seen on unenhanced images is vir-
Fig. 1—Contrast-enhanced ultrasound images of
tually pathognomonic for angiomyolipoma grade 2 clear cell renal cell carcinoma small renal
(AML) [34] (Fig. 4). So-called “fat-poor” mass. (Courtesy of Atri M, University of Toronto,
AMLs are more difficult to discern on CT Toronto, ON, Canada)
studies. Identifying more than 20 pixels with A, Image shows standard ultrasound in preinjection
phase.
attenuation less than −20 HU and more than B, Image shows postinjection phase with contrast
5 pixels at less than −30 HU may be predic- enhancement.

1268 AJR:196, June 2011

 1267 02.07.13

Treatment Planning for Small Renal Masses

proximately 5% or less; 94% specificity and Fig. 2—CT and MRI scans of
grade 2 clear cell renal cell
100% sensitivity have been reported with a carcinoma small renal mass.
cutoff of 15% enhancement [39]. A and B, Images are axial (A)
and coronal (B) venous phase
Diagnostic Needle Core Biopsy: CT scans.
C and D, Images are coronal
Safety, Technique, and Results (C) and axial (D) MRI scans.
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Concerns about safety and accuracy have

limited the application of percutaneous nee-
dle biopsy to provide a histologic diagnosis
before treatment. However, excellent results
have been recently reported in several large
series that advocate the use of routine preop-
erative needle biopsy to characterize the his-
tologic profile of all small renal masses [40,
41]. The standard treatment is now nephron-
sparing partial nephrectomy, and radical
nephrectomy is reserved for special cases.
However, in the largest recent series of lapa-
roscopic partial nephrectomies, 28–34% of
removed tumors were benign [42].
Lane et al. [43] called for a renaissance
of renal mass biopsy; in their meta-analysis,
there was increased accuracy and decreased
nondiagnostic rates after 2001, and compli- and proximal ureter, as defined in the classic [25]. Some authors report a desirable surgical
cations were very uncommon [43]. The risk report by Robson et al. in 1969 [46], which de- margin of 0.5 cm, whereas other literature sup-
of tumor seeding is now estimated to be less fined the principles of kidney removal be- ports the oncologic safety of a negative mar-
than 0.01% [44]. Core biopsy and fine-nee- cause of kidney cancer that are followed gin, irrespective of size [48]. Patients under-
dle aspiration with the use of biopsy needle even today. The cancer-specific survival rate going radical nephrectomy are at greater risk
sheaths and modern imaging techniques pro- for pT1a tumors is 97% [47]. There is a trend of chronic renal insufficiency than are similar
vide diagnostic tissue in about 80% of cases. toward organ-preserving strategies that is patients undergoing partial nephrectomy, with
In the event of nondiagnostic biopsy, it can be supported by most existing guidelines [21, equivalent oncologic outcomes [49]. Huang
repeated with similar success rates as for the 25]. Radical nephrectomy is still indicated et al. [50] retrospectively analyzed a cohort of
first biopsy [45]. Biopsy is usually done un- for technically unfavorable lesions because 662 patients for the development of chronic kid-
der local anesthesia by interventional radiol- of their location and comorbidity [25]. ney disease after radical and partial nephrecto-
ogists with a freehand approach. Ultrasound my. The probability of developing chronic kid-
guidance, CT guidance, or combined CT and Partial Nephrectomy ney disease at 3 and 5 years was 20% and 33%,
ultrasound are used to achieve optimal tar- Nephron-sparing partial nephrectomy is now respectively, in the partial nephrectomy group
geting. Core biopsies are performed through the standard treatment for small renal masses and 65% and 77%, respectively, in the radical
a 17-gauge coaxial cannula, which is initially
advanced to the tumor surface.
In summary, adequate pretreatment evalua-
tion of small renal masses will potentially de-
crease unnecessary surgery for benign disease.

Current Treatment Methods

and Results
Radical Nephrectomy
The reference standard treatment of RCC
is radical nephrectomy that includes the sur-
rounding perinephric fascia, hilar lymph nodes,

Fig. 3—CT images of bilateral oncocytoma small renal

masses.
A–C, Images show axial views of right lesion (A) and
left lesion (B) and coronal view (C) of both lesions in
arterial phase.
D–F, Images show axial views of right lesion (D) and
left lesion (e) and coronal view (f) of both lesions in
venous phase.

AJR:196, June 2011 1269

 1267 02.07.13

Stakhovskyi et al.

Fig. 4—CT images of nique showed a lower risk of skin burns [58].
angiomyolipoma small
renal mass.
Percutaneous insertion of the probe with imag-
A and B, Images show ing control under local anesthesia is the most
axial (a) and coronal common approach. Laparoscopic application
(b) views of bilateral requires a surgical procedure, which increases
angiomyolipomas.
the disability, time, and cost.
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Zagoria et al. [59] achieved complete abla-

tion (as measured by the absence of contrast
enhancement on MRI or CT) in 116 (93%) of
125 tumors for the lesions ranged from 0.6
to 8.8 cm (mean, 2.7 cm). They also report-
ed 100% ablation in tumors smaller than 3.7
nephrectomy group (p < 0.0001) [50]. There is in 4% of patients and a mean complication cm [59]. Recently Tracy et al. [60] reported
only one randomized trial, led by the European rate of 6.1%. A recent retrospective analy- an overall 5-year recurrence rate of 90% for
Organization for Research and Treatment of sis of 118 laparoscopic partial nephrectomies 160 patients with lesions smaller than 4 cm
Cancer [51], for tumors less than 5 cm compar- versus 129 robotic partial nephrectomies re- (mean, 2.4 cm). During the follow-up period,
ing partial nephrectomy and radical nephrecto- ported better outcomes for the robotic group three patients developed metastatic disease,
my (n = 541). Complication rates for partial ne- in terms of warm ischemia, intraoperative and one patient died of RCC, yielding 5-year
phrectomy were greater than those for radical blood loss, and length of hospital stay, with actuarial metastasis-free and cancer-specific
nephrectomy; major complications included equivalent overall operating time, pathologic survival rates of 95% and 99%, respectively
hemorrhage (3.1% vs 1.2%), urine leak (4.4% tumor size, and positive surgical margins. [60]. However, there are concerns about the
vs 0%), and reintervention (4.4% vs 2.4%). use of radiologic criteria for the assessment
There are several series reporting cancer-spe- Thermal Ablation Therapy of tumor viability [61].
cific mortality rates of 2.4% and 5.5% at 5 and Radiofrequency ablation—Radiofrequency Cryoablation—Hypothermic ablation de-
10 years, respectively, after partial nephrecto- ablation (RFA) using a needle probe with tem- creases tissue temperature to −40°C, destroy-
my, which are comparable to rates for radical peratures up to 105°C causes cell death and co- ing the tumor by cellular damage resulting
nephrectomy [52, 53]. agulation necrosis [57]. RFA is mostly applied from freezing, apoptosis, coagulation necro-
in monopolar configuration, but a bipolar tech- sis, and immunologic action [62]. When the
Minimally Invasive Surgical Approaches
Minimally invasive surgical procedures for
treating kidney cancer include laparoscopic
radical nephrectomy, laparoscopic partial ne-
phrectomy, and robotic partial nephrectomy.
The proven benefits are cosmetic, reduced
blood loss, shorter hospital stay, less postop-
erative pain, and an earlier return to normal
activities [54]. Laparoscopic partial nephrec-
tomy is a highly challenging surgical proce-
dure that demands specialized laparoscopic
training but has the advantages of reduced op-
erative time, decreased operative blood loss,
and a shorter hospital stay [42]. The most sig-
nificant complications are hemorrhage (1.2–
4.5%), urinary fistula (1.4–17.4%), and rein-
tervention (0–3.8%) [55]. There appear to be
equivalent functional and early oncologic out-
comes [42]. The same robot used for radical
prostatectomy has been used for partial ne-
phrectomy. In a report of 148 patients, Rogers
et al. [56] showed a positive surgical margin

Fig. 5—CT images of grade 1 clear cell renal cell

carcinoma small renal mass.
A, D, and G, Multiple reconstructions are shown in
axial (A), coronal (D), and sagittal (G) views.
B, E, and H, Unenhanced arterial phase images are
shown in axial (B), coronal (E), and sagittal (H) views.
c, f, and I, Unenhanced venous phase images are
shown in axial (C), coronal (F), and sagittal (I) views.

1270 AJR:196, June 2011


Treatment Planning for Small Renal Masses
procedure was initially introduced in 1995,
open surgery was used for probe insertion [63].
A laparoscopic approach may be used for an-
terior tumors, and posterior tumors are ap-
proached percutaneously. The advantages of
the percutaneous approach include shorter hos-
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pitalization time, real-time imaging, decreased
pain, and lower cost, but there is a 15–18% risk
of repeated treatment [64]. A recent report
from Atwell et al. [65] showed the results of 92
percutaneous cryoablation procedures for 91
patients with a mean follow-up of 26 months
and a mean tumor size of 3.4 cm (range, 1.5–7.3
cm). Of the 83 tumors with follow-up longer
than 3 months, they reported only a single case
(1%) of local tumor progression, with a compli-
cation rate of 9%. Laguna et al. [66] reported
a complication rate of 15.5% with laparoscopic
cryoablation in a multicenter study. In a recent
report with short-term follow-up in 44 patients
with RCC, the cancer-specific survival rate was
100% and the overall survival rate was 93.2%
[67]. In a pooled analysis of cryoablation ver-
sus RFA from Kunkle and Uzzo [68], with
1375 kidney tumors, repeat ablation was per-
formed more often after RFA (8.5% vs 1.3%),
and local recurrence was reported to be higher
in the RFA group (12.9% vs 5.2%; p = 0.0001).
High-intensity focused ultrasound—Ablation
of renal masses with high-intensity focused
ultrasound can be performed in both an ex-
tra- and intracorporeal manner, but reported
experience is limited and the major technical
issue is respiratory movement [69].
Image Assessment of Ablation Effect
Imaging changes during RFA treatment
are not well characterized, but the cryother-
apy ice ball is easily appreciated. CT and
MRI are both used for follow-up. Successful
cryoablation results in shrinkage of the tu-
mor, whereas there may be little initial size
decrease with RFA. After RFA, the ablation
zone is histologically wedge shaped [61].
Imaging-visualized ablation zones may ap-
pear to be larger than the actual ablation vol-
ume during the first couple of months after
RFA. The absence of enhancement is a bet-
ter indicator of successful small renal mass
ablation [68]. However, differentiation of the
enhancement of posttreatment granulation
tissue from contrast enhancement of viable
tumor can be challenging. There is no stan-
dard protocol recommendation for frequency
of follow-up imaging after the ablation, but,
in general, after an ultrasound 1–3 months
after the ablation, cross-sectional imaging
should be performed at intervals of 6 months
AJR:196, June 2011 1271
to at least 5 years [18]. Some centers advo-
cate biopsy after ablation, in addition to the
standard contrast-enhanced imaging; they
question the definition of ablative success,
citing the presence of viable tumors in non-
enhancing regions [70]. However, it should
be noted that those biopsies were performed
soon after the procedure, and the treatment ef-
fect may require longer time of surveillance to
become apparent. The majority of local recur-
rences after ablation have been successfully
retreated by subsequent ablation [18].
Active Surveillance
Active surveillance involves careful initial
monitoring for progression, with treatment de-
layed. Imaging plays a crucial role. We recom-
mend biopsy before making a treatment de-
cision in the event that the tumor is benign.
Cross-sectional imaging of the abdomen (with
ultrasound, CT, or MRI) is usually performed
at 3–6-month intervals [3, 71, 72]. At our insti-
tution, patients who enter into the active sur-
veillance program are followed up with CT
at 3, 6, and 12 months; then every 6 months
for 2 years; and yearly thereafter (Fig. 5).
Ultrasound or MRI is acceptable for patients
with contraindications to CT; chest radiogra-
phy is performed annually. Chest radiography
is performed to detect asymptomatic metasta-
sis, whereas monitoring of T1 tumors was sug-
gested by the American College of Radiology
[73]. From our initial Canadian trial experience
with 209 tumors in 178 patients prospectively
enrolled into an initial active surveillance trial,
27 patients (with 34 tumors) have progressed.
The mean small renal mass dimension was 2.1
cm (median, 2.1 cm; range, 0.4–4.0 cm), and
the overall growth rate observed in this cohort
was 0.13 cm/year. Active surveillance is a rela-
tively new approach for the treatment of renal
tumors and is particularly indicated for elderly
and infirm patients [74].
Conclusion
Kidney tumors are increasingly detected
with imaging at an earlier stage, when many
tumors appear to be indolent. The new term
“small renal mass” has become increasing-
ly relevant for today’s radiologic practice.
Many small renal masses are benign. The de-
velopment of new imaging methods and ad-
vancements in techniques have aided in the
detection, evaluation, monitoring of growth
through active surveillance, treatment plan-
ning, and assessment of treatment response
for these tumors. An initial CT- or ultrasound-
guided percutaneous biopsy should be consid-
1267 02.07.13
ered for any patient with a newly diagnosed
small renal mass. The treatment decision
should be made after assessment of age, co-
morbidities, tumor characteristics (i.e., loca-
tion and size), imaging characteristics, and
histologic diagnosis, if available. Initial active
surveillance is a treatment option for many
patients, particularly elderly and infirm pa-
tients. Small renal masses are a distinct entity,
and the clinical approach should be different
from those previously established for RCCs.
Acknowledgment
We thank Mostofa Atri for reviewing the
section on ultrasound.
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