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Evaluation of the incidental kidney lesion

Evaluation of the incidental kidney lesion
Literature review current through: Jan 2024.
This topic last updated: Nov 06, 2023.

INTRODUCTION — With increasing utilization of cross-sectional imaging such as ultrasound (US), computed tomography (CT), and magnetic resonance imaging (MRI), the detection rates of an incidental kidney lesion have increased over time [1,2]. While many incidental kidney lesions can be left alone as they will have no clinical consequences, some are pathologies (eg, renal cell carcinoma, renal pseudoaneurysm) that could have an impact on patient outcomes.

Here we describe an approach for evaluating an incidental kidney lesion. The goal of the evaluation is to select those that require further management from those that can be left alone because they are of no clinical significance. The management of kidney lesions once they have been labeled with a suspected diagnosis is described in:

(See "Simple and complex kidney cysts in adults".)

(See "Renal angiomyolipomas (AMLs): Management".)

(See "Diagnostic approach, differential diagnosis, and management of a small renal mass".)

(See "Clinical manifestations, evaluation, and staging of renal cell carcinoma".)

The diagnostic approach to a kidney lesion found during evaluation for urinary-related symptoms would be different than the approach described here. The management of such kidney lesions are described in UpToDate according to their clinical presentation.

APPROACH TO THE DIFFERENTIAL DIAGNOSIS — An incidental kidney lesion is one detected on imaging performed for reasons other than for evaluation of urinary signs or symptoms [3].

The diagnostic approach to the incidental kidney lesion is to differentiate the vast majority of those that require no further evaluation from those that require referral for management. If the lesion does not demonstrate features characteristic of a specific diagnosis at detection, dedicated kidney imaging is performed. Based on the imaging features, the lesion is left alone as having no clinical consequences or triaged for further management that includes surveillance imaging, biopsy, or treatment targeted toward the suspected diagnosis.

Most incidental kidney lesions are cysts, which are seen in up to 40 percent of adults who undergo abdominal computed tomography (CT) [2]. Simple cysts represent the most commonly detected incidental kidney lesion. They are benign, asymptomatic lesions that rarely require treatment [4,5]. However, among other incidental kidney lesions are benign tumors (eg, angiomyolipoma, oncocytoma), malignant tumors (eg, renal cell carcinoma), and vascular lesions (eg, arteriovenous fistula, renal artery aneurysm, or pseudoaneurysm) [6-10]. These also typically present as incidental kidney lesions but do require further patient evaluation and treatment.

LESIONS SOMETIMES DIAGNOSED AT PRESENTATION — Some incidental lesions can be diagnosed based on imaging features at detection (table 1).

Simple cyst — Simple cysts are the most commonly encountered incidental kidney lesions. In the Bosniak system for classifying kidney cysts, they belong in category I (table 2) [11]. If an incidental kidney lesion demonstrates imaging features of a simple cyst at presentation, no further evaluation is warranted. (See "Simple and complex kidney cysts in adults", section on 'Diagnosis of simple cysts'.)

Hemorrhagic or proteinaceous cyst — A benign hemorrhagic or proteinaceous cyst may be diagnosed with noncontrast CT if all the following criteria are met [3,12]:

Does not contain fat (ie, no fat attenuation)

Homogenous internal fluid of ≥70 Hounsfield units (HU)

A thin wall without mural nodules

No septa or calcifications

Cysts with these characteristics on noncontrast CT do not require further evaluation.

Angiomyolipoma — Angiomyolipomas are benign neoplasms comprised of smooth muscle, adipose, and epithelioid cells. They can be diagnosed on CT or MRI if they demonstrate macroscopic fat. However, up to 5 percent of angiomyolipomas have no visible fat. (See "Renal angiomyolipomas (AMLs): Epidemiology, pathogenesis, clinical manifestations, and diagnosis", section on 'Clinical manifestations'.)

By US, angiomyolipomas are hyperechoic, although US cannot reliably distinguish them from other hyperechoic lesions. By CT, angiomyolipomas are hypoattenuating (<-10 HU) with variable contrast enhancement (image 1). By MRI, angiomyolipomas are T1-hyperintense with variable contrast enhancement and lose signal on fat suppression sequences (image 2) [13,14]. (See "Renal angiomyolipomas (AMLs): Epidemiology, pathogenesis, clinical manifestations, and diagnosis", section on 'How to establish a diagnosis'.)

Vascular abnormalities — Vascular abnormalities include aneurysms, pseudoaneurysms, arteriovenous fistulas, and arteriovenous malformations. They may be congenital or sequela of trauma, inflammation, or interventions such as biopsy, percutaneous nephrostomy, or partial nephrectomy. By Doppler US, these lesions generally have high velocity turbulent blood flow (image 3) [9,10]. On CT or MRI with contrast administration, these lesions have a characteristic tubular or saccular form that follows the enhancement pattern of blood vessels (image 3 and image 4). Such lesions may require intervention to reduce the risk of hemorrhage. (See 'Vascular abnormalities' below.)

Malignancy — Solid contrast-enhancing lesions measuring >4 cm in diameter and containing no fat on CT or MRI have a greater than 90 percent likelihood of being malignant [6,15]. By US, such lesions will have variable echogenicity, smooth or irregular margins, and may have areas of vascularity visible by Doppler. However, these lesions cannot be reliably diagnosed by US and usually require tissue diagnosis and/or additional cross-sectional imaging for staging and treatment planning. (See "Clinical manifestations, evaluation, and staging of renal cell carcinoma".)

While smaller, solid enhancing lesions are more likely to be benign than their larger counterparts, over 80 percent of solid enhancing lesions measuring 1 to 4 cm are malignant [6,15]. Most are renal cell carcinomas, and some are high grade or advanced stage. Among patients with a known nonrenal primary malignancy, they can also represent metastases [16]. (See '<1 cm solid enhancing mass' below and '1 to 4 cm solid enhancing mass' below and "Diagnostic approach, differential diagnosis, and management of a small renal mass".)

Lesion measuring <3 cm stable for over five years — With incidental kidney lesions measuring <3 cm lacking specific radiographically concerning features of malignancy (eg, growth into adjacent vessels or collecting system, lymphadenopathy), the patient's medical record should be searched for prior imaging examinations to assess for stability.

No change in appearance (eg, contour, number of septa, internal heterogeneity, attenuation, signal, or echotexture) or change in size indicates a stable lesion [3,17,18]. Longitudinal surveillance series indicate that such lesions rarely metastasize and are probably either benign or indolent renal cell carcinoma [19,20]. Hence, lesions demonstrating long-term (ie, >5 years) stability are thought unlikely to impact patient outcome over the ensuing decade [21,22].

DEDICATED KIDNEY IMAGING — While some incidental kidney lesions can be diagnosed at detection, many require dedicated kidney imaging before a management decision can be made.

Choice of imaging modality — With the exception of simple and some hemorrhagic or proteinaceous cysts (see 'Hemorrhagic or proteinaceous cyst' above), abdominal computed tomography (CT) or magnetic resonance imaging (MRI) without and with contrast tailored for kidney lesion characterization is usually required to manage incidental kidney lesions [23]. The image acquisition protocols for kidney lesion characterization are more stringent than those for routine abdominal imaging and, therefore, most patients require another dedicated CT or MRI examination (with kidney mass protocol) following the one on which the lesion was incidentally detected.

In patients with severe kidney function impairment (ie, estimated glomerular filtration rate [eGFR] <30 mL/min/1.73 m2), iodinated contrast agents may be contraindicated. Instead, MRI without and with gadolinium or ultrasound without and with contrast should be performed. However, the use of group I gadolinium-based contrast agents should be avoided in such patients. (See "Patient evaluation prior to oral or iodinated intravenous contrast for computed tomography", section on 'Patients with eGFR <30' and "Patient evaluation before gadolinium contrast administration for magnetic resonance imaging", section on 'Patients with eGFR <30 mL/min/1.73 m2 or with acute kidney injury'.)

In most practice settings where contrast-enhanced US is not available, MRI without contrast is performed as the second-line option. MRI without contrast is preferred over CT without contrast because the former yields more tissue-specific information. In this setting, addition of diffusion weighted sequences and analysis of apparent diffusion coefficient maps may improve diagnostic accuracy [24,25].

Availability of imaging technology and expertise at the site usually drives the choice between CT versus MRI for kidney lesion characterization. However, MRI is generally preferred for small lesions (eg, <1.5 cm) [3]. As intravenous contrast is routinely given for this indication, a history of an acute adverse reaction to iodinated contrast for CT or to gadolinium-based contrast for MRI may determine the choice. Other patient-related factors include indwelling electrical or metallic implants or severe claustrophobia, both of which are relative contraindications to MRI. (See "Patient evaluation prior to oral or iodinated intravenous contrast for computed tomography", section on 'Patients with past reactions to contrast' and "Patient evaluation before gadolinium contrast administration for magnetic resonance imaging", section on 'Patient with history of reaction to gadolinium contrast' and "Patient evaluation for metallic or electrical implants, devices, or foreign bodies before magnetic resonance imaging".)

CT and MRI imaging — Visual and, in some cases, quantitative assessment for solid tissue that enhances with intravenous contrast are the most important aspects of the dedicated kidney imaging examination. The protocol is also directed at detecting fluid, fat, or calcification within the lesion. Abdominal CT or MRI that include kidneys within the field of view but obtained for other indications (eg, MRI of the lumbar spine, CT of the abdomen for pain, etc) will usually not be sufficient to fully characterize a kidney lesion.

Dedicated CT or MRI for kidney lesion evaluation is characterized by high resolution images through the kidneys before and after contrast administration. Typically, axial ≤5 mm-thick slices through the kidneys before and after bolus administration of intravenous contrast is performed. Postcontrast imaging is acquired in the nephrographic phase of the bolus to assess lesion enhancement. Subtraction imaging of pre- from postcontrast images are sometimes created to increase the conspicuity of enhancing tissue [26,27]. With dual energy CT, where virtual noncontrast images can be generated after iodine quantification, postcontrast images alone may be sufficient for kidney lesion characterization and affords diagnostic accuracy comparable with pre- and postcontrast imaging with conventional CT [28,29].

Additional steps in the imaging protocol vary with each practice and are intended to improve diagnostic accuracy. With CT, multiplanar reformats in the coronal and sagittal plane improve conspicuity for small enhancing kidney masses [30,31]. With MRI, T1-weighted images without and with fat saturation and T2-weighted images are obtained before intravenous contrast administration for tissue characterization (eg, fat, hemorrhage, fluid) [32]. Some practices include imaging in the arterial and/or venous phase after bolus contrast administration for vessel evaluation and/or in the excretory phase to evaluate the intrarenal collecting system for urothelial malignancies that can present as a central kidney mass.

Both CT and MRI demonstrate high sensitivities (approximately 90 percent) for detecting renal cell carcinoma [33]. MRI, with greater capability for soft tissue contrast, has a higher specificity than CT (89 versus 75 percent, respectively) and, hence, results in fewer false-positive diagnoses.

Effective radiation dose of CT for kidney lesion evaluation is approximately 5 to 10 mSv. MRI does not involve radiation exposure for the patient.

Limited use of contrast-enhanced ultrasound — US assessment enables differentiation of a cystic versus solid incidental kidney lesion. With addition of Doppler, it can often characterize high flow vascular lesions (eg, aneurysms, pseudoaneurysms, arteriovenous fistulas). Intravenous contrast is administered to assess enhancement of the solid components. US contrast agents can be given safely to patients with severe kidney function impairment in whom CT or MRI contrast agents are relatively contraindicated. However, contrast-enhanced ultrasound is not a widely available technology and the data regarding its diagnostic performance, albeit growing, remain limited [34-37].

LESIONS NOT REQUIRING FURTHER MANAGEMENT AFTER KIDNEY IMAGING — Following dedicated kidney imaging, some incidental lesions are characterized as clinically insignificant, requiring no additional management.

Pseudotumor — Renal pseudotumors are developmental variants or sequela of prior infection that mimic a renal neoplasm on ultrasound (US). These include a prominent column of Bertin (image 5 and image 6), a dromedary hump of the left kidney, a persistent fetal lobulation, and severe scarring with adjacent hypertrophy of the renal parenchyma. Clinical scenarios suggestive of a pseudotumor include a solitary kidney, which are more likely to demonstrate a hypertrophied column of Bertin or a history of vesicoureteral reflux, pyelonephritis, or treatments for nephrolithiasis, which may result in scarring. Pseudotumors can be diagnosed based on their characteristic appearance on dedicated kidney imaging with computed tomography (CT) or magnetic resonance imaging (MRI).

Bosniak I or II cyst — Incidental cystic kidney lesions are classified based on the degree of complexity (eg, solid component, calcifications) and categorized on their likelihood of underlying malignancy according to the Bosniak criteria [5]. Bosniak I (ie, simple cyst) and Bosniak II (ie, minimally complex cysts) are benign and require no further evaluation (image 7). (See "Simple and complex kidney cysts in adults", section on 'Management according to Bosniak category'.)

LESIONS REQUIRING FURTHER MANAGEMENT AFTER KIDNEY IMAGING — Following dedicated kidney imaging, some incidental lesions require treatment or follow-up.

Lesions with equivocal enhancement on CT — A kidney lesion with an increase in attenuation between 10 and 20 Hounsfield units (HU) following intravenous contrast is defined as demonstrating equivocal enhancement [3]. These could represent a solid mass with low-grade enhancement (eg, papillary renal cell carcinoma) or a benign cyst. Usually, these are further evaluated with magnetic resonance imaging (MRI), which affords greater tissue contrast to differentiate soft tissue from fluid. However, contrast-enhanced ultrasound (US) or dual-energy computed tomography (CT) may be chosen for further evaluation in some practices, depending on the availability of necessary technology and expertise.

Bosniak IIF, III, or IV cyst — Bosniak IIF, III, and IV lesions include benign complex cysts and cystic renal cell carcinomas (image 8 and image 9). The likelihood of underlying malignancy in a cystic kidney lesion increases with its complexity and the corresponding Bosniak category. Reported rates of malignancy from observational series range between 25 to 85 percent, depending on the category [38,39]. Consequently, these lesions require additional evaluation that involves surveillance imaging, biopsy, or resection. (See "Simple and complex kidney cysts in adults", section on 'Management according to Bosniak category'.)

Angiomyolipoma — Angiomyolipomas require further management because of the risk for hemorrhage, which depends partly on their size and growth rate [40,41]. (See "Renal angiomyolipomas (AMLs): Management".)

Focal infection — Focal pyelonephritis (image 10), abscess, or xanthogranulomatous pyelonephritis can present as an incidental kidney lesion. The diagnosis is suspected based on appearance of inflammation or edema surrounding the lesion in patients with chronic nephrolithiasis or history of recurrent urinary tract infections, and confirmed with urinalysis and, rarely, biopsy. (See "Xanthogranulomatous pyelonephritis" and "Renal and perinephric abscess".)

Vascular abnormalities — Aneurysms, pseudoaneurysms, and arteriovenous fistulas or malformations are associated with hematuria and a risk for hemorrhage. They are managed with surveillance or treated with endovascular embolization or resection.

Aneurysms — Surgical or endovascular repair or, if needed, nephrectomy is indicated for a renal arterial aneurysm that displays one of the following features:

Size ≥2 cm

Growth on serial imaging

Dissection

Thrombus with evidence of distal embolization

Associated with kidney ischemia and hypertension or with local symptoms (eg, flank pain, hematuria)

In a woman of child-bearing age who is likely to conceive

Aneurysms with none of these features are usually managed with periodic CT or MRI to ensure stability.

Pseudoaneurysms and arteriovenous fistulas or malformations — Pseudoaneurysms and arteriovenous fistulas are a sequela of trauma, either spontaneous or iatrogenic (eg, biopsy, partial nephrectomy, percutaneous nephrostomy); arteriovenous malformations are congenital. These vascular abnormalities may be managed expectantly or treated with endovascular embolization depending on the clinical circumstances.

The majority of fistulas occurring after needle biopsy are diagnosed because of symptoms, most commonly pain or hematuria. Postbiopsy fistulas are likely underdiagnosed and most resolve spontaneously [42]. Fistulas diagnosed immediately after kidney trauma have also been noted to resolve spontaneously.

Treatment with endovascular embolization is indicated for pseudoaneurysms and arteriovenous fistulas or malformations that demonstrate:

Associated symptoms (eg, hypertension, heart failure, severe hematuria, worsening kidney function)

Growth on serial imaging

Rupture on imaging

Lack of spontaneous resolution after 18 months

<1 cm solid enhancing mass — Surveillance is generally the most reasonable course of action for these lesions. Details are discussed elsewhere. (See "Diagnostic approach, differential diagnosis, and management of a small renal mass", section on 'Active surveillance'.)

The size cutoff of <1 cm is accepted by most radiologists and urologists because such small lesions result in a low yield of diagnostic biopsies and generally have high rates of benign histology. Approximately 60 percent of <1 cm kidney lesions that are selected for resection prove to be renal cell carcinoma [15]. However, malignant lesions measuring <1 cm typically demonstrate indolent tumor biology, with low rates of metastatic progression and slow linear growth rates on surveillance [15,43-46].

1 to 4 cm solid enhancing mass — Solid lesions that measure 1 to 4 cm in diameter and enhance on dedicated kidney imaging with CT or MRI are categorized as small renal masses (image 11).

Although the majority are renal cell carcinomas, approximately 20 percent are benign tumors (eg, fat-poor angiomyolipoma, oncocytoma) [6,15,43]. Management options include resection, thermal ablation, and active surveillance with some undergoing biopsy for pathologic diagnosis before treatment. The management of these lesions is discussed separately. (See "Diagnostic approach, differential diagnosis, and management of a small renal mass", section on 'Management approach'.)

>4 cm solid enhancing mass — Most incidentally detected solid enhancing kidney lesions measuring >4 cm in diameter are renal cell carcinoma [6,15]. The patient should be further evaluated with this presumptive diagnosis. Staging involves chest imaging, and pathologic confirmation of the diagnosis is obtained with surgical resection or, less commonly, needle biopsy. (See "Clinical manifestations, evaluation, and staging of renal cell carcinoma", section on 'Diagnostic evaluation'.)

SUMMARY AND RECOMMENDATIONS

Definition and goal – An incidental kidney lesion is one detected on imaging performed for reasons other than for evaluation of urinary signs or symptoms. The goal of the diagnostic approach is to differentiate the vast majority of those that require no further evaluation from those that require referral for management (table 1). (See 'Approach to the differential diagnosis' above.)

Lesions sometimes diagnosed at presentation – Some incidental lesions can be diagnosed based on imaging features at detection. These include simple cysts, angiomyolipomas, vascular abnormalities, and some malignancies. (See 'Lesions sometimes diagnosed at presentation' above.)

Dedicated kidney imaging – Many incidental lesions require further evaluation with abdominal computed tomography (CT) or magnetic resonance imaging (MRI) without and with contrast tailored for kidney lesion characterization. Availability of imaging technology and expertise and patient contraindications (eg, history of contrast allergy) drive the choice of modality. (See 'Dedicated kidney imaging' above.)

Lesions not requiring further management – After CT or MRI dedicated for kidney lesion characterization, further management is not necessary for a lesion diagnosed as a pseudotumor or a Bosniak I or II cyst (see 'Lesions not requiring further management after kidney imaging' above).

Lesions requiring further management – After CT or MRI dedicated for kidney lesion characterization, further management is necessary for a lesion diagnosed as equivocally enhancing on CT; a Bosniak IIF, III, or IV cyst; angiomyolipoma; focal infection; vascular abnormality; or a solid enhancing mass. (See 'Lesions requiring further management after kidney imaging' above.)

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Topic 116643 Version 18.0

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