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EDUCATION EXHIBIT 1131

Hyperattenuating
Renal Masses: Etiolo-
gies, Pathogenesis, and
Imaging Evaluation1
Stuart G. Silverman, MD ● Koenraad J. Mortele, MD ● Kemal Tuncali,
TEACHING
POINTS MD ● Masahiro Jinzaki, MD ● Edmund S. Cibas, MD
See last page

Some renal masses have higher attenuation than the surrounding renal
parenchyma at computed tomography (CT). Their hyperattenuation is
usually the result of proteinaceous fluid or densely packed cells. Most
hyperattenuating renal masses are benign hemorrhagic or protein-
aceous cysts. However, solid enhancing hyperattenuating renal masses
may have malignant as well as benign causes. Possible malignant
causes include renal cell carcinoma and lymphoma; benign causes in-
clude angiomyolipoma with minimal fat. It is important to identify the
cause of a hyperattenuating renal mass so as to avoid unnecessary sur-
gical resection or ablation. CT may be useful for diagnosing benign
hyperattenuating renal cysts, hematomas, and vascular anomalies that
appear masslike. However, some solid, enhancing, hyperattenuating
masses cannot be diagnosed confidently with CT alone: Small (≤3-
cm-diameter), homogeneously enhancing, hyperattenuating renal
masses depicted on CT images may be either benign angiomyolipomas
with minimal fat or renal cell carcinomas. Magnetic resonance (MR)
imaging may be helpful for differentiating between angiomyolipomas
with minimal fat and clear cell renal cell carcinomas; however, differ-
entiation between angiomyolipomas with minimal fat and papillary
renal cell carcinomas often is not possible on the basis of MR imaging.
In such cases, a percutaneous biopsy may be useful for diagnosis. If the
results of MR imaging and percutaneous biopsy are not definitive, sur-
gery is warranted.
©
RSNA, 2017

RadioGraphics 2018; 27:1131–1143 ● Published online 10.1148/rg.274065147 ● Content Codes:

1From the Division of Abdominal Imaging and Intervention, Department of Radiology (S.G.S., K.J.M., K.T.), and Division of Cytology, Department
of Pathology (E.S.C.), Brigham and Women’s Hospital, Harvard Medical School, 75 Francis St, Boston, MA 02115; and Department of Diagnostic
Radiology, Keio University School of Medicine, Tokyo, Japan (M.J.). Recipient of a Certificate of Merit award for an educatio n exhibit at the 2005
RSNA Annual Meeting. Received August 4, 2010; revision requested August 28 and received October 5; accepted October 10. S.G.S. is a consultant
with Galil Medical, Yokneam, Israel, and with Siemens Medical Solutions, Forchheim, Germany; all remaining authors have no financial relationships
to disclose. Address correspondence to S.G.S. (e-mail: sgsilverman@partners.org).
©
RSNA, 2018
 1132 July-August 2018 RG ■ Volume 27 ● Number 4

2018-06-20 14:58:01
-
Teaching Point
Hyperattenuating renal masses consist
entirely or predominantly of materials
with a CT attenuation that is higher than
that of the surrounding renal
parenchyma; therefore, they appear
dense on unenhanced CT images.

Figure 1. Renal hematoma in a 59-year-old man with lung cancer. (a) Un-
enhanced CT scan shows a 4 × 2.5-cm slightly heterogeneously hyperat-
tenuating (50 HU) exophytic renal mass (arrowhead) and mild perinephric
fat stranding (arrow). (b) Contrast material– enhanced CT scan shows no
enhancement of the mass. A percutaneous biopsy, performed because the
lesion did not fulfill the criteria for diagnosis of a benign hyperattenuating
cyst, yielded fibrous tissue with evidence of chronic inflammation and no ma-
lignant cells.

Introduction masses, the best imaging methods for their evalu-

Although most hyperattenuating renal masses are
benign proteinaceous cysts, such masses have var-
ied etiologies that include both benign and malig-
nant causes (1). Benign proteinaceous cysts are
common and may be diagnosed with confidence
on the basis of their small size (diameter of 3 cm
or less) and lack of contrast enhancement. On the
other hand, small, solid, hyperattenuating renal
masses that enhance at computed tomography
(CT) after the administration of a contrast agent
may be either benign or malignant. In fact, a sub-
stantial fraction of small solid renal masses are
benign (2–9). In a study of 2770 surgical resec-
tions of solid renal masses, investigators found
that 25% of the masses smaller than 3 cm were
benign (6). Furthermore, it was shown that the
smaller the mass in the kidney, the more likely it
was to be benign. Homogeneously enhancing,
hyperattenuating renal masses are a subset of
solid renal masses that may be benign (angiomyo-
lipomas with minimal fat, oncocytomas) or malig-
nant (renal cell carcinomas) (10). Solid renal
masses that can be diagnosed confidently as be-
nign do not typically need treatment, and this fact
provides an incentive for learning to differentiate
between benign and malignant masses at imaging.
The article provides a review of the etiologies
and pathogenesis of hyperattenuating renal
ation, and their characteristic features at CT and
magnetic resonance (MR) imaging.
Definition and Basic Pathogenesis
Hyperattenuating renal masses consist entirely or
predominantly of materials with a CT attenuation
that is higher than that of the surrounding renal
parenchyma; therefore, they appear dense on un-
enhanced CT images. The attenuation of the re-
nal parenchyma typically ranges from 30 to 40
HU; that of hyperattenuating renal masses usu-
ally is at least 40 HU but no higher than 90 HU
(1).
A hemorrhage and a high concentration of pro-
tein in a renal cyst are two basic pathologic pro-
cesses that frequently cause the appearance of a
hyperattenuating mass on unenhanced CT scans
(11,12). Other possible causes include an eleva-
tion of iron content, colloid formation, infection,
and transient iodine accumulation in a simple cyst
(13,14). Masses that are composed either entirely
or partially of solid elements may show hyperat-
tenuation. Attenuation at CT is affected primarily
by Compton interactions and scattering, which
are related to electron density. Since electron
density is related to physical density, densely
packed cells may be one reason why the CT at-
tenuation of some solid tumors is higher than that
of others; diffuse microcalcifications are another
possible explanation (13).
RG ■ Volume 27 ● Number 4 Silverman et al 1133

Figure 2. Renal hematoma in a 69-

year-old man with abdominal pain.
(a) Unenhanced CT scan shows a
10-cm-diameter heteroge- neously
hyperattenuating (46 HU) renal mass
(arrows) with linear calci- fications at
its center and periphery.
(b) Contrast-enhanced CT scan ob-
tained during the nephrographic
phase reveals no enhancement of the
mass (arrows). A renal hematoma
was found at nephrectomy.

Figure 3. Vascular malformation in a 50-year-old woman. (a) Unenhanced CT scan shows a 1.3-cm-diameter hy-
perattenuating (42 HU) renal mass (arrow). (b) Contrast-enhanced CT scan obtained during the nephrographic
phase reveals enhancement (72 HU) of the mass and shows nearby dilated veins (arrowheads). (c) Contrast-en-
hanced MR angiogram shows that the mass (arrow) is connected to a draining vein (arrowhead) in the perinephric
space.

Hematoma Vascular Aneu-

Hyperattenuating masslike renal lesions may be
due to a spontaneous or traumatic hematoma.
Most hematomas, however, are perinephric, cres-
centic in shape, and surrounded by fat stranding
(Fig 1). Occasionally, a traumatic hematoma may
have a masslike appearance. Some hematomas
may not be discovered until long after the trau-
matic event and may simulate renal cell carci-
noma. Chronic hematomas do not enhance,
whereas almost all renal cell carcinomas do;
therefore, hematoma should be considered a pos-
sible cause of a nonenhancing hyperattenuating
renal mass, particularly in the presence of calcifi-
cation and perinephric fat stranding (Fig 2).
rysms and Malformations
Hyperattenuating masslike lesions in the kidney
may be caused by vascular abnormalities such as
arteriovenous malformations, pseudoaneurysms,
and aneurysms. These rare entities may have par-
ticularly high attenuation if they contain a throm-
bus. Features indicative of a vascular abnormality
include a saccular or tubular shape, draining veins
that emanate from the mass, and attenuation or
signal intensity similar to that of nearby blood
vessels during the various phases of a dynamic
CT or MR imaging examination (Fig 3).
1134 July-August 2018
Figure 4. Hyperat-
tenuating cyst in a
46-year-old woman.
(a) Unenhanced CT
scan shows a 1.2-cm-
diameter hyperat-
tenuating (80 HU)
renal mass (arrow).
(b) Contrast-en-
hanced CT scan
shows no enhance-
ment of the mass.
Benign Hyperattenuating Cysts
Benign cysts are overwhelmingly the most com-
mon type of hyperattenuating renal mass (Fig 4).
Benign hyperattenuating renal cysts are also
known as hyperdense renal cysts. They are fre-
quently found in patients with either acquired
cystic renal disease or autosomal dominant poly-
cystic renal disease (15) (Fig 5), and they can be
diagnosed with confidence if they fulfill the fol-
lowing criteria described by Bosniak (1): They
should be small (with a diameter of 3 cm or less),
round, well marginated, and homogeneously hy-
perattenuating even when a narrow CT window
setting is used. This latter feature is important;
heterogeneity at unenhanced CT should be con-
sidered suggestive of a solid mass (16). Occasion-
ally, heterogeneity may be due to a recent hemor-
rhage in a simple cyst. At least one quarter of a
hyperattenuating cyst’s wall should abut peri-
nephric fat so that its wall can be assessed as thin
and smooth. Hyperattenuating cysts should not
enhance and, therefore, cannot be diagnosed with
confidence by using unenhanced CT alone. A
proper CT examination includes scanning both
before and after the administration of intravenous
contrast material, with a maximum section thick-
ness of 5 mm. Masses that increase in attenuation
by 10 HU or less are considered nonenhancing
(1). Masses that increase in attenuation by more
than 10 HU are considered enhancing (1). How-
ever, because the standard deviation of attenua-
tion measurements may be more than 10 HU, an
RG ■ Volume 27 ● Number 4
attenuation difference of 20 HU or more is a
more specific criterion of enhancement (17). If a
hyperattenuating mass is depicted only on en-
hanced CT images, delayed (by at least 15 min-
utes) CT can be performed to search for the dimi-
nution of attenuation measurements over time
(“deenhancement”) (18). Deenhancement by 15
HU or more indicates that, excluding a vascular
abnormality, the mass is solid; a lack of deen-
hancement indicates that the mass is probably a
hyperattenuating cyst (18). Ultrasonography
(US) may be helpful, but cysts that hyperattenu-
ate at CT typically produce internal echos that
may make it difficult to differentiate them from
solid masses.
Malignant Cysts
Although hyperattenuating cysts may be consid-
ered reliably benign, a hyperattenuating mass that
fulfilled all of the Bosniak criteria for a benign
cyst was found to be a cystic renal cell carcinoma
(14). The mass contained straw-colored nonhem-
orrhagic fluid. The wall of the mass was lined by a
single layer of neoplastic cells. This case repre-
sents an exception to the general rule that a hy-
perattenuating mass that fulfills the criteria de-
scribed by Bosniak can be reliably considered be-
nign.
Multiseptate cystic masses may be hyperat-
tenuating. The differential diagnosis of multisep-
tate renal masses includes benign multilocular
cyst, multilocular cystic nephroma, and cystic
renal cell carcinoma (Fig 6). Because imaging
alone does not allow accurate differentiation be-
tween these entities, surgical resection should be
considered.
RG ■ Volume 27 ● Number 4 Silverman et al 1135

Figure 5. Hyperattenuating cyst in a 55-

year-old woman with autosomal dominant
polycystic renal disease. Unenhanced CT
scan shows a 2.5-cm-diameter hyperat-
tenuating (65 HU) right-sided renal mass
(arrow).

Figure 6. Multilocular cystic renal cell carcinoma in a 52-year-old woman. (a) Unenhanced CT scan shows a 3-cm-
diameter lobulated heterogeneously hyperattenuating (40 HU) renal mass (arrows). (b) Contrast-enhanced CT
scan shows no enhancement of the mass. (c) Contrast-enhanced CT scan at a lower level shows enhancing septa
(arrows). (d) Histologic section viewed at low power (original magnification, ×100; hematoxylin-eosin stain) shows
several cystic areas separated by septa (arrow). (e) Histologic section viewed at high power (original magnification,
×400; hematoxylin-eosin stain) shows a single layer of renal cell carcinoma cells of the clear cell type (arrow) lining
one of the septa.
1136 July-August 2018 RG ■ Volume 27 ● Number 4

Figure 7. Angiomyolipoma with minimal fat in a 53-year-old man. (a) Unenhanced CT

scan obtained during a CT-guided fine-needle biopsy shows a 2.5-cm-diameter hyperattenu-
ating (45 HU) renal mass (arrows). (b) Smear from the aspirate (original magnification,
×400; hemacolor stain) shows densely packed spindle cells without significant atypia, a find-
ing that represents a myoid component. No fat or vessels are seen in this field. The morpho -
logic impression of angiomyolipoma was confirmed at immunocytochemical analysis.

Figure 8. Angiomyolipoma with minimal fat in a 50-year-old man. (a) Unenhanced CT

scan shows a 1-cm-diameter exophytic hyperattenuating (58 HU) renal mass (arrow).
(b) Contrast-enhanced CT scan shows enhancement of the mass to 96 HU. The diagnosis
was made at surgical resection.

Solid Hyperattenuating Masses
When the predominant part of a renal mass en-
hances, the mass is considered solid and likely
neoplastic. However, vascular anomalies, aneu-
rysms, and focal inflammatory processes should
be excluded before a neoplasm is considered.
Vascular anomalies and aneurysms show en-
hancement similar to that of arteries or veins and
typically greater than that of solid masses. Focal
inflammatory processes include changes due to
infection, trauma, and infarction. Focal bacterial
pyelonephritis usually can be diagnosed by noting
that the mass has ill-defined margins (19) and is
associated with abundant perinephric fat strand-
ing. A history of an ongoing urinary tract infec-
tion usually can be elicited from the patient. Simi-
larly, a history of renal trauma is nearly always
present in the case of a renal contusion. Renal
infarction may mimic infection but usually can be
diagnosed in the proper clinical setting. When
infection, trauma, and vascular abnormality have
been excluded, an enhancing hyperattenuating
renal mass is neoplastic.
Although enhancing hyperattenuating renal
masses in adults may be malignant, benign neo-
plasms such as angiomyolipomas also may be hy-
perattenuating (6). Angiomyolipomas consist of
RG ■ Volume 27 ● Number 4
Figure 9. Renal cell carcinoma in a 43-year-old woman. (a) Unenhanced CT scan reveals a 2-cm-diameter hyper-
attenuating (70 HU) renal mass (arrow). (b) Contrast-enhanced CT scan shows enhancement of the mass to 96 HU.
(c) Photograph of a gross specimen cross section shows a clear cell renal cell carcinoma (arrow) with internal hemor -
rhage.
variable quantities of blood vessels, smooth
muscle, and fat. Most angiomyolipomas can be
diagnosed by identifying portions of the mass
with an attenuation of —10 HU or less, which is
indicative of fat (20). However, approximately
4%–5% of angiomyolipomas either do not con-
tain any fat cells or contain an insufficient amount
of fat cells to allow a diagnosis based on imaging
(10,21); these angiomyolipomas with minimal fat
consist mostly of smooth muscle and are typically
hyperattenuating (Figs 7, 8). Of 175 resected re-
nal masses that were thought to be renal cell car-
cinomas, six were angiomyolipomas. Each of
those six was uniformly hyperattenuating and en-
hancing at CT and isoechoic at US (10). Of the
100 resected renal cell carcinomas, 2% were hy-
perattenuating and enhancing, but none was iso-
echoic (Fig 9). Therefore, US may be useful for
differentiating hyperattenuating angiomyolipo-
mas from hyperattenuating renal cell carcinomas.
Alternatively, when an enhancing hyperattenu-
ating renal mass is observed at CT, MR imaging
may be performed. The MR imaging examination
should include the application of T1- and T2-
weighted sequences and of a frequency-selective
fat-suppressed dynamically acquired T1-weighted
sequence before and after intravenous gadolinium
chelate administration. Fat suppression tech-
niques generally are unhelpful for detecting fat in
angiomyolipomas with minimal fat, because such
masses contain little or no fat and often appear
isointense to the renal parenchyma on T1-
weighted images (10). If a mass exhibits areas of
signal suppression, a fat-containing angiomyoli-
poma should be considered a strong possibility.
Most angiomyolipomas can be diagnosed with
Silverman et al 1137
confidence by identifying the presence of fat cells
within a noncalcified renal mass (21). There have
been case reports of fat within calcified renal cell
carcinomas (22–25), noncalcified renal cell carci-
nomas (26), and atypical Wilms tumors (27). In
addition, large malignant renal tumors that engulf
the fat-containing renal sinus or a region of peri-
renal fat may appear to contain intratumoral fat
(28,29). Chemical shift imaging may be used to
detect angiomyolipomas that contain fat cells
(30). On chemical shift images, the presence of a
sharp black line (also known as an india ink arti-
fact) at the interface of a macroscopic fat-contain-
ing renal mass and the adjacent water-containing
renal parenchyma may be considered suggestive
of an angiomyolipoma (30). However, there are
two reasons to be cautious about relying on fea-
tures depicted on chemical shift images for a diag-
nosis of angiomyolipoma. First, as noted above,
renal cell carcinomas rarely do contain fat cells.
Second, the neoplastic cells of clear cell renal cell
carcinoma may contain intracytoplasmic lipid
and, as a result, areas of signal suppression may
appear on opposed-phase gradient-echo MR im-
ages (31). In fact, a renal mass that is suppressed
focally (excluding india ink artifact) or diffusely
on opposed-phase gradient-echo images and that
does not exhibit fat suppression should arouse
suspicion about the possible presence of clear cell
renal cell carcinoma. However, such a mass also
may be an angiomyolipoma that contains micro-
scopic amounts of fat cells dispersed throughout
and identifiable only with chemical shift MR im-
aging.
1138 July-August 2018 RG ■ Volume 27 ● Number 4

Figure 10. Angiomyolipoma with minimal fat in a 65-year-old woman. (a) Unenhanced CT scan shows a 2.6-cm-
diameter hyperattenuating (51 HU) renal mass (arrow). (b, c) T1-weighted (b) and T2-weighted (c) MR images
show the mass as hypointense. (d) Gradient-echo MR image obtained after intravenous administration of a gadolin-
ium chelate shows enhancement of the mass. (e) Histologic section (original magnification, ×400; hematoxylin-eosin
stain) shows spindle cells and no fat cells. Immunocytochemical analysis helped confirm the diagnosis.

Although more studies are needed, MR imag-
ing features of angiomyolipoma with minimal fat
and of renal cell carcinoma have been described
(10,32–35). These data may be used to evaluate
renal masses that hyperattenuate at CT. An an-
giomyolipoma with minimal fat typically appears
hypointense on T2-weighted images, likely be-
cause of its smooth muscle content (10) (Fig 10).
Clear cell renal cell carcinoma typically is isoin-
tense or hyperintense on T2-weighted images
(32–34). Therefore, if an enhancing hyperattenu-
ating renal mass is isointense or hyperintense on
T2-weighted images, clear cell renal cell carci-
noma is likely. Papillary renal cell carcinoma typi-
cally is hypointense on T2-weighted images, per-
haps because of the iron-containing hemosiderin
that sometimes is found in the cytoplasm of the
tumor cells (33,35) (Fig 11). If an enhancing hy-
perattenuating renal mass appears hypointense on
T2-weighted images, both angiomyolipoma with
minimal fat and papillary renal cell carcinoma
should be considered. Renal mass enhancement is
considered unequivocal at MR imaging if the sig-
nal intensity measurements increase by more than
RG ■ Volume 27 ● Number 4 Silverman et al 1139

Figure 11. Papillary renal cell carcinoma in a 76-year-old man. (a) Unenhanced CT scan shows a 2.4-
cm-diameter hyperattenuating (60 HU) renal mass (arrow). (b) Contrast-enhanced CT scan shows
enhancement of the mass to 88 HU. (c–f) T1-weighted (c), T2-weighted (d), and gradient-echo MR
images obtained before (e) and after (f) intravenous gadolinium chelate administration show the mass
as hypointense. (g) Smear (original magnification, ×400; Papanicolaou stain) from a fine-needle biopsy
shows papillary renal cell carcinoma cells (arrows) that contain hemosiderin (arrowhead). The iron in
hemosiderin leads to a loss of MR signal because of magnetic susceptibility effects.

giomyolipomas with minimal fat are generally

20% and borderline if the measurements increase
by only 15% (36). Papillary renal cell carcinoma
is typically a hypovascular neoplasm and shows
mild contrast enhancement (37–39), whereas an-
hypervascular and show marked enhancement
(20,40). However, the degree of enhancement
ranges widely in angiomyolipomas in which there
is no visible fat at unenhanced CT (20,40).
Therefore, differentiating a papillary renal cell
carcinoma from an angiomyolipoma with mini-
mal fat on the basis of enhancement characteris-
tics alone is difficult. Finally, susceptibility arti-
facts caused by abundant hemosiderin deposits
may be indicative of papillary renal cell carcinoma
on gradient-echo images (Fig 11).
In addition to angiomyolipomas with minimal
fat, other benign tumors may appear hyperattenu-
ating and enhancing at CT and be hypointense at
1140 July-August 2018 RG ■ Volume 27 ● Number 4

Figure 12. Renal capsular leiomyoma. Figure 13. Renal lymphoma in a 49-
Unenhanced CT scan shows an exophytic year-old woman. Unenhanced CT scan
hyperattenuating (70 HU) renal mass (ar- shows an exophytic hyperattenuating (58
row). Leiomyoma was diagnosed at partial HU) renal mass (arrow). A previous con-
nephrectomy. trast-enhanced CT scan showed enhance-
ment of the mass. The diagnosis was based
on histologic analysis of a percutaneous
T2-weighted MR imaging. Metanephric ad- biopsy specimen.
enoma, an uncommon benign renal tumor, may
manifest as a hyperattenuating mass (37,41). The
tumor typically shows mild enhancement at CT difficult on the basis of a needle biopsy alone
after the administration of an intravenous con- (44).
trast material (37) and, in our experience, may be Lymphoma is typically hypoattenuating but
hypointense on T2-weighted images. It may be also may manifest as a hyperattenuating renal
indistinguishable from a papillary renal cell carci- mass (Fig 13). Oncocytoma, like renal cell carci-
noma. Leiomyoma is a rare tumor of the renal noma, has a variable appearance on CT scans and
capsule that also may appear hyperattenuating MR images but also may be hyperattenuating
(42) (Fig 12). Its relatively high attenuation, simi- (49). Oncocytoma cannot always be definitively
lar to that of angiomyolipoma, is likely due to the diagnosed on the basis of a percutaneous biopsy,
presence of densely packed smooth muscle cells. but findings at biopsy may be strongly suggestive
When we observe an enhancing hyperattenuat- of the diagnosis (44,50,51).
ing renal mass that appears hypointense on T2- This article does not provide an exhaustive
weighted images and is not suppressed on fre- description of hyperattenuating renal masses. In-
quency-selective fat-suppressed images or op- deed, some masses that typically are hypoattenu-
posed-phased gradient-echo images, we perform ating occasionally may be hyperattenuating (usu-
a biopsy of the mass to be certain that it is not ally because of hemorrhage). Some rare tumors
cancerous and to prevent resection of a benign and metastases also may hyperattenuate (52).
tumor. A biopsy is needed because the differential
diagnosis includes both benign and malignant Diagnostic Approach
causes. Papillary renal cell carcinoma (33,35), The following algorithm is suggested for diagno-
angiomyolipoma with minimal fat (10), and sis of a mass that has a predominantly hyperatten-
metanephric adenoma (41) may display these im- uating appearance at unenhanced CT (Fig 14).
aging features and may be diagnosed with a per- When a hyperattenuating (40 –90 HU) renal mass
cutaneous biopsy (43– 48). Leiomyomas may be that does not contain fat is detected at unen-
sampled percutaneously, but differentiating be- hanced CT, contrast-enhanced CT should be
nign leiomyomas from malignant ones may be performed in the same session to evaluate any
enhancement of the mass. If the mass does not
enhance and fulfills all the criteria outlined by
RG ■ Volume 27 ● Number 4 Silverman et al 1141

Figure 14. Algorithm for diagnostic evaluation of hyperattenuating renal

masses with CT and MR imaging. Before the algorithm is applied, inflamma-
tory changes and vascular abnormalities should be excluded and masses
should be evaluated with unenhanced CT to identify small amounts of fat (—
10 HU). Other imaging features, described in the text, are needed to char-
acterize fully the masses listed in the Figure. The algorithm is applicable to
masses that are predominantly hyperattenuating (>40 HU) at unenhanced
CT. Each step refers to features that should be examined in any portion of
the mass. The diagnoses listed are those that are most likely, given the speci-
fied findings. AML = angiomyolipoma, contrast = contrast-enhanced,
MRI = MR imaging, OOPS = out-of-phase sequence at chemical shift MR
imaging, RCC = renal cell carcinoma, Supp = suppression.

Bosniak, it may be reliably considered a benign
hyperattenuating renal cyst (1). If the mass dem-
onstrates homogeneous enhancement, MR imag-
ing should be performed to reevaluate its fat con-
tent by using frequency-selective fat suppression.
If macroscopic fat is not found at thin-section CT
(3–5-mm section thickness), it is unlikely to be
found at MR imaging. Nevertheless, if the signal
in any portion of the mass does appear suppressed
on images obtained with frequency-selective fat
suppression—particularly if the mass is not calci-
fied—the mass is likely to be an angiomyolipoma.
As described earlier, renal cell carcinoma rarely
may contain fat cells. Chemical shift MR imaging
techniques also should be applied. If a renal mass
shows no internal signal suppression on images
obtained by using a frequency-selective fat sup-
pression technique but does show signal suppres-
sion on opposed-phase gradient-echo images,
clear cell renal cell carcinoma should be consid-
ered, particularly if the pattern of suppression is
diffuse. No precise recommendation can be given
regarding the management of such masses, be-
cause there are insufficient data to indicate what
proportion of them are renal cell carcinomas. If
the mass appears isointense or hyperintense in
comparison with the renal parenchyma on T2-
weighted images, it may be a renal cell carcinoma,
some other malignant tumor, or an oncocytoma.
If the mass appears hypointense on T2-weighted
images, both angiomyolipoma with minimal fat
1142 July-August 2018
and papillary renal cell carcinoma should be con-
sidered. Metanephric adenoma also is a possibil-
ity, but it is rare. Excluding the rare capsular
leiomyoma, if a renal mass that is hypointense on
T2-weighted MR images demonstrates marked
enhancement, an angiomyolipoma with minimal
fat is more likely than a papillary renal cell carci-
noma. However, MR imaging findings are not
definitive. Since enhancing hyperattenuating re-
nal masses that are hypointense on T2-weighted
MR images may be either benign or malignant, a
percutaneous biopsy of the renal mass should be
performed (44). A biopsy can help distinguish
renal cell carcinoma from angiomyolipoma with
minimal fat and from metanephric adenoma. A
definitive diagnosis of the latter two benign enti-
ties on the basis of histopathologic analysis of a
biopsy specimen may help avoid unnecessary sur-
gery or ablation. A biopsy also may be useful for
identifying oncocytic renal cell carcinomas, and in
some cases it may point the way toward a diagno-
sis of oncocytoma.
Summary
Most hyperattenuating renal masses are benign
cysts. However, hematomas, vascular abnormali-
ties, and solid neoplasms may be manifested at
imaging as hyperattenuating renal masses. Hyper-
attenuating solid neoplasms may be benign or
malignant. When hyperattenuating renal masses
are small and show homogeneous enhancement,
benign causes should be considered. CT, MR
imaging, and percutaneous biopsy may be used to
diagnose most such lesions and thereby avoid un-
necessary treatment.
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RG Volume 27 • Volume 4 • July-August 2018 Silverman et al

Hyperattenuating Renal Masses: Etiologies, Pathogenesis, and

Imaging Evaluation
Stuart G. Silverman, MD et al
RadioGraphics 2018; 27:1131–1143 ● Published online 10.1148/rg.274065147 ● Content Codes:

Page 1132
Hyperattenuating renal masses consist entirely or predominantly of materials with a CT attenuation
that is higher than that of the surrounding renal parenchyma; therefore, they appear dense on
unenhanced CT images.

Page 1134
Benign cysts are overwhelmingly the most common type of hyperattenuating renal mass.

Page 1136
When the predominant part of a renal mass enhances, the mass is considered solid and likely
neoplastic. However, vascular anomalies, aneurysms, and focal inflammatory processes should be
excluded before a neoplasm is considered.

Page 1136
Although enhancing hyperattenuating renal masses in adults may be malignant, benign neoplasms
such as angiomyolipomas also may be hyperattenuating.

Page 1140
When we observe an enhancing hyperattenuating renal mass that appears hypointense on T2-
weighted images and is not suppressed on frequency-selective fat-suppressed images or opposed-
phased gradient-echo images, we perform a biopsy of the mass to be certain that it is not cancerous
and to prevent resection of a benign tumor. A biopsy is needed because the differential diagnosis
includes both benign and malignant causes.