Radiologic assessment of renal masses: implications for patient care

The relationships between the gross pathologic features of neoplastic and nonneoplastic renal masses and their radiologic analogues, described above, establish specific guidelines for the influence of radiologic studies on clinical management. A tumor that contains fat, as determined with CT or MR imaging, can be confidently diagnosed as an angiomyolipoma without further diagnostic intervention. The size of the lesion should be used to influence clinical decisions related to the fact that angiomyolipomas larger than 4 cm in diameter are more apt to hemorrhage than those smaller than that size. High confidence can also be assigned to those renal masses that exhibit the radiologic analogues for hemangioma with use of imaging modalities that document their vascular nature. These findings should be sufficient for therapeutic decisions directed toward embolization or surgical excision when clinically warranted. If a mass can be characterized as a simple cyst by satisfying all of the required CT or sonographic criteria, no further diagnostic interventions are required. This includes the radiologic findings of thin rim of peripheral calcification and thin septa with or without calcification. An equally high level of confidence is associated with the broad range of CT, sonographic, or MR imaging findings that indicate malignant tumor. These militate for radical surgery. However, the same findings are also encountered in hemorrhagic and infected renal cyst, abscess, benign neoplasms, and inflammatory mass. Therefore, surgical excision, the nature of which will vary according to individual circumstances, is usually required to establish these diagnoses. Exceptions to the need for a tissue diagnosis might be considered in the patient in whom a renal mass is detected in the clinical setting of infection and in the patient with either a small asymptomatic renal mass or a small hyperattenuating mass that meets the other criteria of a simple cyst. Here again, individual circumstances may lead to such alternatives as aspiration of the mass for culture, interval follow-up to seek evidence of growth, or dismissal.