Stepwise algorithm using computed tomography and magnetic resonance imaging for diagnosis of fat-poor angiomyolipoma in small renal masses: Development and external validation.

Abstract

To develop a stepwise diagnostic algorithm for fat-poor angiomyolipoma in small renal masses. Two cohorts of small renal masses <4cm without an apparent fat component that was pathologically diagnosed were included: 153 cases (18 fat-poor angiomyolipomas/135 renal cell carcinomas) for model development and 71 cases (seven fat-poor angiomyolipomas/59 renal cell carcinomas/5 oncocytomas) for validation. Dynamic contrast-enhanced computed tomography, magnetic resonance imaging and clinical findings were analyzed. Based on multivariate analysis, we developed two prediction models for fat-poor angiomyolipoma, the computed tomography model and the computed tomography+magnetic resonance imaging model, and a stepwise algorithm that proposes the sequential use of computed tomography and magnetic resonance imaging. The computed tomography model, which was composed of female aged <50years, high attenuation on unenhanced computed tomography, less enhancement than the normal renal cortex and homogeneity in the corticomedullary phase, differentiated tumors with none of the factors as the low angiomyolipoma-probability group, and the others were candidates for the computed tomography+magnetic resonance imaging model. The computed tomography+magnetic resonance imaging model, consisting of the first three factors of the computed tomography model, low signal intensity and absence of pseudocapsule on T2-weighted magnetic resonance imaging, re-stratified the tumors into low, intermediate and high angiomyolipoma-probability groups. The incidence of fat-poor angiomyolipoma in each group was 0%, 26% and 93%, respectively (area under the curve 0.981). External validation by two readers showed a high area under the curve (0.912 and 0.924) for each. The interobserver agreement was good (kappa score 0.77). The present algorithm differentiates fat-poor angiomyolipoma in small renal masses with high accuracy by adding magnetic resonance imaging to computed tomography in selected patients.