Oncology| Volume 125, P123-130, March 2019

Using Aorta-Lesion-Attenuation Difference on Preoperative Contrast-enhanced Computed Tomography Scan to Differentiate Between Malignant and Benign Renal Tumors

Published:December 12, 2018DOI:



      To evaluate the ability of Aorta-Lesion-Attenuation Difference (ALAD) to differentiate malignant renal tumors from renal oncocytomas.


      A retrospective review of preoperative computed tomography (CT) scans and surgical pathology was performed on patients undergoing partial nephrectomy for small, solid renal masses. ALAD was calculated by measuring the difference in Hounsfield units (HU) between the aorta and the lesion of interest on the same image slice on preoperative CT scan. The discriminative ability of ALAD to differentiate malignant pathology from oncocytoma was evaluated by sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and area under curve (AUC) using receiver operating characteristic analysis.


      A total of 227 preoperative CT scans and corresponding pathology reports were reviewed. ALAD values were calculated during the excretory and nephrographic phases. Nephrographic ALAD was able to differentiate malignant pathology from oncocytoma using a HU threshold of 24 with a sensitivity of 84%, specificity of 86%, PPV of 98%, and NPV of 33%. The AUC for malignant pathology vs oncocytoma was 0.86 (95% confidence intervals 0.77-0.96). Nephrographic ALAD was able to differentiate chromophobe renal cell carcinoma (RCC) from oncocytoma using a HU threshold of 24 with a sensitivity of 100%, specificity of 86%, PPV of 75%, and NPV of 100%. The AUC for chromophobe RCC vs oncocytoma was 0.98 (95% confidence intervals 0.91-1.00).


      ALAD discriminates well between chromophobe RCC and oncocytoma, which may aid in the management of patients with indeterminate diagnoses of oncocytic neoplasm on diagnostic needle biopsy. Further validation of ALAD will be necessary prior to routine use in clinical practice.
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        • Delahunt B
        • Srigley JR
        • Montironi R
        • Egevad L
        Advances in renal neoplasia: recommendations from the 2012 International Society of Urological Pathology Consensus Conference.
        Urology. 2014; 83: 969-974
        • Linehan WM
        • Pinto PA
        • Bratslavsky G
        • et al.
        Hereditary kidney cancer: unique opportunity for disease-based therapy.
        Cancer. 2009; 115: 2252-2261
        • Hollingsworth JM
        • Miller DC
        • Daignault S
        • Hollenbeck BK
        Rising incidence of small renal masses: a need to reassess treatment effect.
        J Natl Cancer Inst. 2006; 98: 1331-1334
        • Lane BR
        • Babineau D
        • Kattan MW
        • et al.
        A preoperative prognostic nomogram for solid enhancing renal tumors 7 cm or less amenable to partial nephrectomy.
        J Urol. 2007; 178: 429-434
        • Frank I
        • Blute ML
        • Cheville JC
        • Lohse CM
        • Weaver AL
        • Zincke H
        Solid renal tumors: an analysis of pathological features related to tumor size.
        J Urol. 2003; 170: 2217-2220
        • Patel HD
        • Druskin SC
        • Rowe SP
        • Pierorazio PM
        • Gorin MA
        • Allaf ME
        Surgical histopathology for suspected oncocytoma on renal mass biopsy: a systematic review and meta-analysis.
        BJU Int. 2017; 119: 661-666
        • Jewett MA
        • Mattar K
        • Basiuk J
        • et al.
        Active surveillance of small renal masses: progression patterns of early stage kidney cancer.
        Eur Urol. 2011; 60: 39-44
      1. Gordetsky J, Eich ML, Garapati M, Del Carmen Rodriguez Pena MM, Rais-Bahrami S. Active surveillance of small renal masses. Urology 2018 (in press).

        • Campbell S
        • Uzzo RG
        • Allaf ME
        • et al.
        Renal mass and localized renal cancer: AUA guideline.
        J Urol. 2017; 198: 520-529
        • Dhyani M
        • Grajo JR
        • Rodriguez D
        • et al.
        Aorta-Lesion-Attenuation-Difference (ALAD) on contrast-enhanced CT: a potential imaging biomarker for differentiating malignant from benign oncocytic neoplasms.
        Abdom Radiol. 2017; 42: 1734-1743
        • Gaudiano C
        • Schiavina R
        • Vagnoni V
        • et al.
        Can the multiphasic computed tomography be useful in the clinical management of small renal masses?.
        Acta Radiol. 2017; 58: 625-633
        • Choi JH
        • Kim JW
        • Lee JY
        • et al.
        Comparison of computed tomography findings between renal oncocytomas and chromophobe renal cell carcinomas.
        Korean J Urol. 2015; 56: 695-702
        • Pierorazio PM
        • Hyams ES
        • Tsai S
        • et al.
        Multiphasic enhancement patterns of small renal masses (≤4 cm) on preoperative computed tomography: utility for distinguishing subtypes of renal cell carcinoma, angiomyolipoma, and oncocytoma.
        Urology. 2013; 81: 1265-1271
        • Youden WJ
        Index for rating diagnostic tests.
        Cancer. 1950; 3: 32-35
        • Patel HD
        • Johnson MH
        • Pierorazio PM
        • et al.
        Diagnostic accuracy and risks of biopsy in the diagnosis of a renal mass suspicious for localized renal cell carcinoma: systematic review of the literature.
        J Urol. 2016; 195: 1340-1347
        • Gorin MA
        • Rowe SP
        • Allaf ME
        Noninvasive determination of renal tumor histology utilizing molecular imaging.
        Urol Oncol. 2016; 34: 525-528
        • Kutikov A
        • Smaldone MC
        • Egleston BL
        • et al.
        Anatomic features of enhancing renal masses predict malignant and high-grade pathology: a preoperative nomogram using the RENAL Nephrometry score.
        Eur Urol. 2011; 60: 241-248
        • Canvasser NE
        • Kay FU
        • Xi Y
        • et al.
        Diagnostic accuracy of multiparametric magnetic resonance imaging to identify clear cell renal cell carcinoma in cT1a renal masses.
        J Urol. 2017; 198: 780-786
        • Cornelis F
        • Tricaud E
        • Lasserre AS
        • et al.
        Routinely performed multiparametric magnetic resonance imaging helps to differentiate common subtypes of renal tumours.
        Eur Radiol. 2014; 24: 1068-1080
        • Rosenkrantz AB
        • Hindman N
        • Fitzgerald EF
        • Niver BE
        • Melamed J
        • Babb JS
        MRI features of renal oncocytoma and chromophobe renal cell carcinoma.
        AJR Am J Roentgenol. 2010; 195: W421-W427
        • Gorin MA
        • Rowe SP
        • Baras AS
        • et al.
        Prospective evaluation of (99m)Tc-sestamibi SPECT/CT for the diagnosis of renal oncocytomas and hybrid oncocytic/chromophobe tumors.
        Eur Urol. 2016; 69: 413-416
        • Rowe SP
        • Gorin MA
        • Gordetsky J
        • et al.
        Initial experience using 99mTc-MIBI SPECT/CT for the differentiation of oncocytoma from renal cell carcinoma.
        Clin Nucl Med. 2015; 40: 309-313
        • Gormley TS
        • Van Every MJ
        • Moreno AJ
        Renal oncocytoma: preoperative diagnosis using technetium 99m sestamibi imaging.
        Urology. 1996; 48: 33-39
        • Tzortzakakis A
        • Gustafsson O
        • Karlsson M
        • Ekström-Ehn L
        • Ghaffarpour R
        • Axelsson R
        Visual evaluation and differentiation of renal oncocytomas from renal cell carcinomas by means of.
        EJNMMI Res. 2017; 7: 29