Association of Clear Cell Likelihood Score on MRI and Growth Kinetics of Small Solid Renal Masses on Active Surveillance

BACKGROUND. The lack of validated imaging markers to characterize biologic aggressiveness of small renal masses (SRMs)-defined as those categorized as cT1a and 4 cm and smaller-hinders medical decision-making among available initial management strategies. OBJECTIVE. The purpose of this article was to explore the association of the clear cell likelihood score (ccLS) on MRI with growth rates and progression of SRMs. METHODS. This retrospective study included consecutive SRMs assigned a ccLS on clinical MRI examinations performed between June 2016 and November 2019 at an academic tertiary-care medical center or its affiliated safety net hospital system. The ccLS reports the likelihood that the SRM represents clear cell renal cell carcinoma (ccRCC) from 1 (very unlikely) to 5 (very likely). The ccLS was extracted from clinical reports. Tumor size measurements were extracted from available prior and follow-up cross-sectional imaging examinations, through June 2020. Serial tumor size measurements were fit to linear and exponential growth curves. Estimated growth rates were grouped by the assigned ccLS. Tumor progression was defined by development of large size (> 4 cm in at least two consecutive measurements) and/or rapid growth (doubling of volume within 1 year). Differences among ccLS groups were evaluated using Kruskal-Wallis tests. Correlations between ccLS and growth rate were evaluated by Spearman correlation (ρ). RESULTS. Growth rates of 386 SRMs (100 ccLS 1-2, 75 ccLS 3, and 211 ccLS 4-5) from 339 patients (median age, 65 years; 198 men, 141 women) were analyzed. Median follow-up was 1.2 years. The ccLS was correlated with growth rates by size (ρ = 0.19; p < .001; ccLS 4-5, 9%/year; ccLS 1-2, 5%/year; p < .001) and by volume (ρ = 0.14; p = .006; ccLS 4-5, 29%/year; ccLS 1-2, 16%/year; p < .001). Disease progression (observed in 49 SRMs) was not significantly associated with ccLS group (p = .61). Two patients (0.6%) developed metastases during active surveillance: one ccLS 1 was a type 2 papillary renal cell carcinoma and one ccLS 4 was ccRCC. CONCLUSION. Growth is associated with ccLS in SRMs, with higher ccLS correlating with faster growth. CLINICAL IMPACT. SRMs with lower ccLS may be considered for active surveillance, whereas SRMs with higher ccLS may warrant earlier intervention. The noninvasive ccLS derived from MRI correlates with growth rate of SRMs and may help guide personalized management.