158.

fm — 12/7/07
Prasad et al. Genitourinar y Imaging • Review
Benign Renal Neoplasms

Benign Renal Neoplasms in Adults:

Cross-Sectional Imaging Findings
Srinivasa R. Prasad1 OBJECTIVE. A broad spectrum of benign renal neoplasms in adults shows characteristic
Venkateswar R. Surabhi1 ontogeny, histology, and tumor biology. Benign renal tumors are classified into renal cell tu-
Christine O. Menias2 mors, metanephric tumors, mesenchymal tumors, and mixed epithelial and mesenchymal tu-
Abhijit A. Raut3 mors. Select benign tumors show characteristic anatomic distribution and imaging features.
Kedar N. Chintapalli1 However, because of overlapping of findings between benign and malignant renal tumors, his-
tologic evaluation may be required to establish a definitive diagnosis. Accurate preoperative
Prasad SR, Surabhi VR, Menias CO, Raut AA, characterization facilitates optimal patient management.
Chintapalli KN CONCLUSION. We attempt to provide a comprehensive, contemporary review of benign
renal neoplasms that occur in adults, focusing on cross-sectional imaging characteristics.

enign renal neoplasms that occur 79% sample adequacy [7]. However, patholo-

B in adults constitute a heteroge-

neous group of tumors with char-
acteristic histology and variable
clinicobiologic profiles. The 2004 World
Health Organization (WHO) classification
schemata categorizes benign renal neoplasms
on the basis of histogenesis (cell of origin)
and histopathology [1] (Appendix 1). Renal
neoplasms are thus classified into renal cell,
metanephric, mesenchymal, and mixed epi-
thelial and mesenchymal tumors.
Keywords: benign tumors, CT, kidney, MRI, renal
neoplasms, sonography
Recent advances in imaging technology
have resulted in the detection of incidental renal
DOI:10.2214/AJR.07.2724 masses in seemingly asymptomatic patients.
Although renal cell carcinoma (RCC) is by far
Received June 13, 2007; accepted after revision
the most lethal urologic malignancy, benign tu-
July 16, 2007.
mors constitute a significant proportion of
1Department of Radiology, University of Texas Health masses in patients who undergo surgery. In a re-
Science Center at San Antonio, 7703 Floyd Curl Dr., cent study of 143 patients with presumed soli-
San Antonio, TX 78229. Address correspondence to tary RCC, the authors found 16.1% of patients
S. R. Prasad (prasads@uthscsa.edu).
who underwent partial nephrectomy had be-
2Department of Radiology, Mallinckrodt Institute of nign masses [2]. Other studies have also found
Radiology, St. Louis, MO. that a significant proportion of solid renal
masses are histologically benign [3–5]. Also,
3Department of Radiology, King Edward Memorial Hospital,
percutaneous renal mass biopsy is being in-
Mumbai, India.
creasingly performed to preoperatively charac-
CME terize renal masses and to establish definitive
This article is available for CME credit. See www.arrs.org diagnoses [3, 4, 6, 7]. Recent advances in histo-
for more information. pathology, immunocytochemistry, and cytoge-
AJR 2008; 190:158–164
netics assist in fairly accurate characterization
of most renal masses and help guide optimal
0361–803X/08/1901–158
patient management [1, 7, 8]. A recent study of
© American Roentgen Ray Society 66 renal mass biopsies found 98% accuracy and
gists advise caution when interpreting tumors,
specifically those with oncocytic features or hy-
brid or collision tumors [7, 9]. Laparoscopic
partial nephrectomies and percutaneous abla-
tions are being increasingly performed to treat
small renal tumors and to establish a definitive
diagnosis [10, 11].
Renal Cell Neoplasms
Oncocytoma
Oncocytoma is a benign renal cell neoplasm
that accounts for approximately 5% of all adult
primary renal epithelial neoplasms in surgical
series [1]. Oncocytoma is hypothesized to
originate from or differentiate toward type A
intercalated cells of the cortical collecting duct
[12, 13]. The peak age of incidence is in the
seventh decade; men are more likely to be af-
fected than women. Most tumors occur spo-
radically in asymptomatic patients.
Oncocytoma is histologically composed of
nests and acini of large polygonal cells with
mitochondria-rich eosinophilic cytoplasm
[1]. Oncocytomas do not show diffuse cyto-
plasmic Hale colloidal iron staining, in con-
tradistinction to chromophobe RCCs.
Oncocytomas typically appear as solitary,
well-demarcated, unencapsulated, fairly ho-
mogeneous renal cortical tumors. Bilateral,
multicentric oncocytomas are seen in heredi-
tary syndromes of renal oncocytosis and Birt-
Hogg-Dubé syndrome (in association with
the chromophobe subtype and other RCC

158 AJR:190, January 2008


Fig. 1—72-year-old man with hereditary oncocytosis
syndrome. Coronal contrast-enhanced CT scan during
nephrographic phase shows bilateral solid renal
masses (arrows) that were characterized as
oncocytomas on histopathology.
subtypes) [14] (Fig. 1). A characteristic cen-
tral stellate fibrotic scar (more often seen with
large tumors) is seen in up to 33% of tumors
[1] (Fig. 2). Hemorrhage may be found in up
to 20% of cases. A spoke-wheel pattern of
feeding arteries associated with a homoge-
neous nephrogram is a characteristic finding
on catheter angiography [15]. However, on-
cocytomas are indistinguishable from renal
cell carcinomas on the basis of imaging find-
ings alone. In addition, oncocytomas may be
associated with RCCs either as hybrid tumors
(pathologic features of both oncocytomas and
chromophobe or other RCC subtypes) or as
collision tumors [9]. Thus, despite advances
in histopathologic techniques (including im-
munocytochemistry and cytogenetics), a par-
tial nephrectomy may be required for accu-
rate characterization [7].
Papillary Adenoma
Papillary adenomas are the most common
renal epithelial neoplasms. According to au-
topsy series, approximately 40% of patients
older than 70 years harbor renal adenomas
[1]. Papillary adenomas are also commonly
found in patients with acquired renal cystic
disease and in patients undergoing long-term
hemodialysis [16]. A papillary adenoma-to-
carcinoma sequence has been described that
is akin to similar transformation in colonic
adenomas [17, 18].
By definition, papillary adenomas measure
5 mm or less [1]. They are usually subcapsu-
lar and solitary. Adenomas are histologically
characterized by papillary or tubular cytoar-
chitecture and frequent psammoma bodies
[1]. Cytogenetic changes of papillary ade-
nomas include loss of the Y chromosome and
combined trisomy of chromosomes 7 and 17
[19]. Histologic and genetic abnormalities of
AJR:190, January 2008
Benign Renal Neoplasms
A B
Fig. 2—64-year-old man with histologically proven oncocytoma. K = kidney.
A, Axial fat-saturated, T2-weighted gradient-refocused echo image shows expansile, solid right renal mass
(arrow) with hyperintense central scar (S).
B, Axial fat-saturated, gadolinium-enhanced T1-weighted 3D gradient-refocused echo image shows right kidney
mass (arrow) with hypointense central scar (S).
renal adenomas are indistinguishable from
papillary RCCs [1, 20].
Papillary adenomas are extremely small
(< 5 mm) and may not be distinguished from
other renal tumors (particularly RCC) and
pseudotumors on imaging studies.
Metanephric Neoplasms
Metanephric neoplasms are a heteroge-
neous group of benign renal neoplasms that
include metanephric adenoma (epithelial tu-
mor), metanephric stromal tumor (stromal
neoplasm), and metanephric adenofibroma
(mixed epithelial and stromal neoplasm) [21].
These tumors are histogenetically related to
Wilms’ tumor and are postulated to represent
the most hyperdifferentiated, benign end of
the nephroblastoma spectrum [21]. Meta-
nephric adenofibromas and metanephric stro-
mal tumors are essentially pediatric tumors
and will not be discussed in this article.
Metanephric adenoma is a benign renal neo-
plasm with peak age of occurrence in the fifth
or sixth decade and a 2:1 female preponder-
ance [1]. Metanephric adenoma is asymptom-
atic in approximately 50% of patients; abdom-
inal pain and hematuria are common clinical
symptoms. Polycythemia, a characteristic
finding seen in approximately 10% of patients
with metanephric adenoma, promptly disap-
pears after surgical resection [22].
Metanephric adenoma is histologically
characterized by the arrangement of monoto-
nous small blue embryonal epithelial cells in
an acinar, tubular, or sheetlike configuration
[21]. Abundant psammoma bodies are com-
monly found.
Metanephric adenoma typically appears as
a well-defined, unencapsulated, solitary solid
mass [21, 22] (Fig. 3). It commonly appears
as a hyperattenuating mass on unenhanced
158.fm — 12/7/07
CT; large tumors appear as heterogeneous,
hypovascular masses with frequent foci of
hemorrhage and necrosis [23, 24]. Calcifica-
tion is seen in 20% of cases. Metanephric ad-
enoma shows a hypointense signal on T1-
weighted MRI and a slightly hyperintense
signal on T2-weighted MRI [25]. Meta-
nephric adenoma appears as an expansile hy-
poechoic or hyperechoic mass on sonogra-
phy. True cystic forms of metanephric
adenoma are rare [26].
Mesenchymal Neoplasms
Angiomyolipoma
Angiomyolipoma (AML) is the most com-
mon benign mesenchymal neoplasm; it is com-
posed of variable proportions of blood vessels,
smooth muscle, and adipose tissue [1]. AMLs
are now included under the umbrella term
“neoplasms of the perivascular epithelioid
cells,” which are also referred to as PEComas
[27]. Renal AMLs consist of two distinct his-
tologic subtypes, classic triphasic and mono-
typic epithelioid. Epithelioid AMLs typically
do not show macroscopic fat and appear as
soft-tissue masses and are thus indistinguish-
able from other solid renal masses. This rare
subtype of AML is potentially malignant and
may exhibit aggressive biology, including re-
currence, metastasis, and death. It will not be
further discussed in this article [27, 28].
Classic AML may occur either sporadi-
cally or in association with tuberous sclerosis
complex (TSC). Sporadic renal AMLs show a
4:1 female preponderance and are more likely
to be solitary and symptomatic [29]. Patients
with TSC harbor small, multicentric, asymp-
tomatic AMLs; 80% of patients with severe
TSC have renal AMLs [30]. The morphology
of AMLs depends on the relative proportions
of various components. Profuse elastin-poor,
159
 158.fm — 12/7/07

Prasad et al.

Fig. 3—Contrast-enhanced axial CT scan in 60-year-
old woman with hematuria shows hypoattenuating,
expansile solid mass (arrows) in left kidney. Radical
nephrectomy showed mass to be metanephric
adenoma. K = kidney.
Fig. 4—43-year-old woman with hematuria. Transverse Fig. 5—58-year-old woman with angiomyolipoma of
sonogram shows uniformly echogenic mass (arrows) kidney. Sagittal contrast-enhanced CT scan shows
in upper pole of left kidney (K) that was proven to be exophytic renal mass (arrows) with foci of
angiomyolipoma. macroscopic fat (arrowhead).

A B
Fig. 6—38-year-old woman with documented tuberous sclerosis complex and renal angiomyolipomas. Fig. 7—55-year-old woman who underwent partial
A, Axial in-phase T1-weighted 2D gradient-refocused echo MR image shows bilateral multicentric renal masses nephrectomy for serendipitously detected renal mass.
that have increased signal intensity (arrows). Axial contrast-enhanced CT scan shows exophytic
B, Axial fat-saturated T2-weighted 2D gradient-refocused echo MR image shows marked drop in signal intensity soft-tissue mass (arrow). Histopathology showed lipid-
of masses (arrows). poor angiomyolipoma.

dysmorphic blood vessels predispose to aneu-
rysm formation and hemorrhage [29]. Large
tumor size (> 4 cm) and diameter of the in-
tralesional aneurysms (> 5 mm) correlate di-
rectly with tumor-related hemorrhage in
AMLs [31].
On sonography, small AMLs appear uni-
formly hyperechoic without a hypoechoic rim
or intralesional cysts [32] (Fig. 4). Large
AMLs appear as variegated masses with mac-
roscopic fat, hemorrhage, and hypervascular
soft-tissue components. Intralesional aneu-
rysms are seen in large tumors as well. The
presence of macroscopic fat on CT or MRI is
characteristic of AMLs (Fig. 5). Loss of sig-
nal intensity on frequency-selective fat-sup-
pressed MRI definitively identifies macro-
scopic fat [30] (Fig. 6). However, a multitude
of renal neoplasms, including RCC, oncocy-
toma, lipoma, and liposarcoma, may show ei-
ther intratumoral fat or engulfed perirenal fat
[33]. Approximately 4.5% of AMLs may not
show identifiable macroscopic fat and are in-
distinguishable from RCC on imaging studies
alone (Fig. 7). Recent studies indicate that in
contradistinction to RCCs, AMLs with mini-
mal fat show uniform, prolonged contrast en-
hancement and a higher signal intensity index
on double-echo, chemical shift FLASH MRI
[34, 35].
Hemangioma
Renal hemangioma is a rare benign mesen-
chymal neoplasm that consists of multiple
endo thelium-lined, blood-filled vascular
spaces [1]. It commonly affects young adults
with no specific sex predilection. Recurrent
episodes of hematuria and renal colic are typ-
ical presenting symptoms; however, inciden-
tal diagnosis in asymptomatic patients is also
common [36]. Hemangiomas of the kidney
may be associated with systemic syndromes
such as Sturge-Weber and Klippel-Trénaunay
and with systemic angiomatosis [1]. Cavern-
ous hemangiomas are more common than the
capillary variants.
Hemangioma of the kidney occurs as an
unencapsulated, unicentric, solitary tumor
that frequently arises from the renal pyra-
mids or the pelvis [1, 37]. Hemangiomas
show variable echogenicity on sonography
and hyperintensity on T2-weighted MRI
[38] (Fig. 8A). Contrast-enhanced CT and
MRI of renal hemangiomas may show
early, intense enhancement (Fig. 8B). Per-
sistent contrast enhancement on delayed
images is fairly characteristic of renal he-
mangiomas [37].
Lymphangioma
Lymphangioma of the kidney is a rare be-
nign cystic tumor that most often arises from
the peripelvic region or renal sinus [1]. It

160 AJR:190, January 2008

 158.fm — 12/7/07

Benign Renal Neoplasms

A B
Fig. 8—60-year-old man with hematuria and histologically proven hemangioma. Fig. 9—47-year-old man with bilateral multiple renal
A, Axial fat-saturated T2-weighted 2D gradient-refocused echo MR image shows hyperintense left kidney mass sinuses and perinephric lymphangiomatosis.
in renal sinus (arrow). Unenhanced axial CT scan shows multicentric cystic
B, Axial fat-saturated gadolinium-enhanced T1-weighted 3D gradient-refocused echo MR image shows contrast masses in renal sinus and perinephric spaces
enhancement of left renal sinus mass (arrows). (arrows).

Fig. 10—43-year-old woman with renal leiomyoma of
capsular origin. Axial contrast-enhanced CT scan
shows large, fairly homogeneous exophytic mass
(arrows) arising from left kidney (K).
Fig. 11—23-year-old woman with hypertension
refractory to standard treatment. Axial unenhanced CT
scan shows large, expansile right renal mass (arrow)
that was histologically proven to be juxtaglomerular
cell neoplasm (reninoma). K = kidney, M = mass.
Fig. 12—57-year-old woman with incidental medullary
fibroma (arrowhead). Patient underwent radical
nephrectomy for renal cell carcinoma (Ca, arrow) of
right kidney.

may also uncommonly arise from the lym-
phatics of the capsule or the cortex [39]. His-
tologically, lymphangiomas consist of com-
municating endothelium-lined spaces that
contain clear fluid [1]. The septa may show
lymphoid cells.
Renal lymphangioma may occur either as
an isolated finding or in association with peri-
nephric or systemic lymphangiomatosis [39].
It may appear as a localized process or a dif-
fusely cystic lesion. Lymphangioma typically
appears as a well-demarcated, uni- or mul-
tilocular cystic neoplasm that most com-
monly arises from the renal sinus region or in
the perinephric space [40, 41] (Fig. 9).
Leiomyoma
Renal leiomyomas are rare benign smooth-
muscle neoplasms that mostly occur in adults
as incidental findings [1]. Renal capsule is the
most common target site of leiomyomas;
rarely, leiomyomas originate from the renal
pelvis or cortex. Intersecting fascicles of spin-
dle cells that show immunoreactivity to actin
or desmin (smooth-muscle markers) are char-
acteristic histologic features [1].
Leiomyomas of the kidney commonly ap-
pear as well-circumscribed, homogeneous, ex-
ophytic solid masses that show uniform en-
hancement on contrast-enhanced CT [42]
(Fig. 10). Larger tumors are heterogeneous be-
cause of hemorrhage and cystic or myxoid de-
generation [43, 44]. Calcification is uncom-
mon. However, the CT findings of leiomyomas
of the kidney may be variable and may include
cystic, complex cystic–solid, or purely solid
morphology [44]. Renal leiomyomas may
show hypervascularity on catheter angiogra-
phy because they are predominantly supplied
by capsular vessels [42, 45].
Juxtaglomerular Cell Neoplasm (Reninoma)
Juxtaglomerular cell (JGC) neoplasm is an
extremely rare, benign renal neoplasm of
myoendocrine cell origin [46]. The peak age
of incidence is in the second and third decades
and a 2:1 female preponderance is seen. JGC
neoplasm is clinically characterized by a triad
of findings: poorly controlled hypertension,
hypokalemia, and high plasma renin activity
[47]. Histologically, JGC neoplasm consists
of sheets of polygonal or spindle cells and a
characteristic, complex, hemangiopericytic
angioarchitecture [1]. The presence of rhom-
boid renin protogranules is diagnostic of JGC
neoplasm [46].
JGC neoplasm typically appears as a uni-
lateral, well-circumscribed, cortical tumor
that usually measures less than 3 cm [13]
(Fig. 11). Despite profuse vascularity, JGC
neoplasms appear hypovascular on contrast-

AJR:190, January 2008 161


Fig. 13—40-year-old woman with histologically proven
mixed epithelial and stromal tumor of kidney. Axial
contrast-enhanced CT scan shows large complex
cystic left kidney (K) mass (arrows) with septations and
solid components.
enhanced CT and MRI, possibly because of
renin-induced vasoconstriction [48, 49]. JGC
neoplasms may show delayed contrast en-
hancement. Imaging findings of JGC neo-
plasms are nonspecific and indistinguishable
from other solid renal neoplasms.
Renomedullary Interstitial Cell Tumor
Also referred to as medullary fibromas,
renomedullary interstitial cell tumors are be-
nign neoplasms that arise from renomedul-
lary interstitial cells, small stellate cells that
are thought to play a role in blood pressure
homeostasis [50]. Renomedullary interstitial
cell tumors are common incidental findings
that are present in 50% of adults in autopsy
series [1].
Most renomedullary interstitial cell tumors
are small and typically measure less than 5
mm. The renal pyramid is the characteristic
location of renomedullary interstitial cell tu-
mors [1]. Rarely, large renomedullary inter-
stitial cell tumors extend into the renal pelvis.
They appear as nonenhancing, hypoattenuat-
ing renal medullary solid lesions without cal-
cification (Fig. 12).
Mixed Epithelial and Mesenchymal
Neoplasms
Mixed epithelial and mesenchymal neo-
plasms comprise two histologically distinct
entities: mixed epithelial and stromal tu-
mors and cystic nephromas. However, re-
cent studies have found remarkable demo-
graphic, clinical, and pathologic similarities
among these entities and a new name, renal
epithelial and stromal tumor, has been pro-
posed [51, 52]. This nomenclature is still
new and has yet to be universally accepted;
we will discuss these two entities separately
162
Prasad et al.
A B
Fig. 14—50-year-old woman with cystic nephroma.
A, Coronal contrast-enhanced CT scan shows lobulated, expansile, cystic mass (M) in left kidney (arrow) that
compresses calyces (C).
B, Coronal T2-weighted MR image shows multilocular, septated cystic mass in left kidney (arrow) that herniates
into renal pelvis. C = calyces.
in this article according to WHO taxonomic
schemata.
Mixed Epithelial and Stromal Tumor
The entity mixed epithelial and stromal tu-
mor was previously called by several descrip-
tive names reflecting variegated tumor histol-
ogy. It is now thought that mixed epithelial
and stromal tumor was previously referred to
as leiomyomatous renal hamartoma, mul-
tilocular cyst with ovarian stroma, cystic
hamartoma of the renal pelvis, and adult me-
soblastic nephroma [53–55]. The unifying
term, mixed epithelial and stromal tumor, was
first coined by Michal and Syrucek in 1998
[56]; two recent large series have largely con-
tributed to our understanding of mixed epithe-
lial and stromal tumors [57, 58].
Mixed epithelial and stromal tumors occur
almost exclusively in perimenopausal women
(6:1 female preponderance); most patients are
receiving estrogen therapy [57, 58]. Twenty-
five percent of the tumors present as inciden-
tal findings; most patients manifest nonspe-
cific symptoms of flank pain and hematuria.
Pathologically, mixed epithelial and stromal
tumor is a benign, bimorphic solid–cystic
neoplasm that consists of epithelium-lined
cysts or microcysts and variably cellular spin-
dle-cell, ovarianlike (estrogen- or progester-
one-receptor positive) stroma [57, 58].
On imaging, mixed epithelial and stromal
tumors typically appear as expansile, com-
plex, cystic–solid masses with heterogeneous
and delayed enhancement [59] (Fig. 13). The
proportion of cystic and solid constituents
varies in any given case. The stromal compo-
nent of the tumor is thought to be responsible
for the hypointense signal on T2-weighted
MRI with delayed contrast enhancement [59].
158.fm — 12/7/07
Large mixed epithelial and stromal tumors
may herniate into the renal pelvis. The tumors
typically show benign biologic behavior
without recurrence or metastasis; however,
aggressive mixed epithelial and stromal tu-
mors with sarcomatous transformation of the
stromal component have been described [60].
Cystic Nephroma
Cystic nephroma is a benign cystic neo-
plasm that affects predominantly middle-aged,
perimenopausal women [1]. Adult-onset cystic
nephroma is histogenetically and morphologi-
cally different from pediatric cystic nephroma
[39, 61]. Morphologically, cystic nephromas
are composed of encapsulated, noncommuni-
cating cysts with thin septations. By definition,
cystic nephromas are characterized by the ab-
sence of a solid component or necrosis [1]. On
histology, the cysts are lined by a monolayer of
hobnail epithelium; the fibrous septa may be
paucicellular or cellular [1].
Cystic nephroma appears as a well-demar-
cated, solitary, multilocular cystic lesion with
thin septations (Fig. 14A). The cystic mass
may protrude into the renal pelvis and cause
hemorrhage or urinary obstruction [62]
(Fig. 14B).
Conclusion
Benign renal tumors that occur in adults
cover a wide spectrum and show character-
istic histology, histogenesis, and anatomic
distribution. Some benign tumors of the kid-
ney (such as angiomyolipomas, mixed epi-
thelial and mesenchymal tumors, leiomyo-
mas, and hemangiomas) show characteristic
imaging findings and regional distribution
that permit their diagnosis (Appendix 2). Al-
though leiomyomas originate from the renal
AJR:190, January 2008

capsule, hemangiomas typically arise from
the renal sinus. Renomedullary interstitial
cell tumors (also known as medullary fibro-
mas) are commonly confined to the renal
medulla. Approximately one third of large
oncocytomas typically show a central stel-
late scar. Cystic nephromas show septated
cysts, macroscopic fat predominates in most
angiomyolipomas, and metanephric ade-
nomas are commonly solid. Mixed epithelial
and stromal tumors consist of solid areas and
cysts that may herniate into the renal pelvis.
However, most benign renal tumors appear
as solid enhancing masses and are thus indis-
tinguishable from the more common malig-
nant renal neoplasms, notably RCCs. Biopsy
of the renal mass may help establish the de-
finitive diagnosis and may obviate aggres-
sive treatment.
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APPENDIX 1: World Health Organization (WHO) Histological Classification of Benign Renal Neoplasms
Renal Cell Tumors Metanephric Tumors
Oncocytoma Metanephric adenoma
Papillary adenoma Metanephric adenofibroma
Metanephric stromal tumor
APPENDIX 2: Making Sense of Adult, Benign Renal Neoplasms: A Pattern-Based Imaging Approach
Soft-Tissue Mass Fatty Mass
Oncocytoma Angiomyolipoma (AML)
Lipid-poor AML
Leiomyoma
Hemangioma
Reninoma
Fibroma
Schwannoma
F O R YO U R I N F O R M AT I O N
This article is available for CME credit. See www.arrs.org for more information.
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AJR:190, January 2008