Renal masses measuring under 2 cm: Pathologic outcomes and associations with MRI features

Purpose To evaluate pathologic outcomes and associations with MRI features in small renal masses measuring up to 20 mm Methods 86 patients (61 ± 13 years; 45 M/41F) with 92 renal masses measuring up to 20 mm that underwent MRI prior to tissue diagnosis were included. Two radiologists independently evaluated all masses for microscopic lipid, hemorrhage, T2-hyperintensity, T2-homogeneity, cystic/necrotic areas, hypervascularity, enhancement homogeneity, circumscribed margins, and predominantly exophytic location. These MRI features, as well as patient age, gender, and history of RCC, were compared with pathologic findings using Fisher's exact test, unpaired t-test, and multivariate logistic regression. Results 26.1% (24/92) of masses under 2 cm were benign, only 32.6% (30/92) were clear-cell RCC, and only 7.6% (7/92) were high-grade. Among 16 masses measuring up to 1 cm, only 12.5% (2/16) were clear-cell RCC, and none was high-grade. Within the entire cohort, no MRI or clinical feature showed a significant difference between benign and malignant lesions (p ≥ 0.053). However, for both readers, clear-cell RCC exhibited a significantly higher frequency of T2-hyperintensity, cystic/necrotic areas, and hypervascularity, and a significantly lower frequency of hemorrhage, T2-homogeneity, and enhancement homogeneity (p < 0.001-0.036). Hypervascularity was a significant independent predictor of clear-cell RCC for both readers (p = 0.002-0.007), as was T2-hyperintensity for reader 2 (p = 0.007). Conclusion A substantial fraction of small renal masses were benign, and when malignant, largely exhibited indolent pathologic characteristics, particularly when measuring under 1 cm Although small benign and malignant masses could not be differentiated on MRI, hypervascularity showed a significant independent association with clear-cell RCC in comparison with other lesions.