Recommendations for the Management of the Incidental Renal Mass in Adults: Endorsement and Adaptation of the 2017 ACR Incidental Findings Committee White.

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Recommendations for the Management of the Incidental Renal Mass in Adults: Endorsement and Adaptation of the 2017 ACR Incidental Findings Committee White Paper by the Canadian Association of Radiologists Incidental Findings Working Group Iain D.C. Kirkpatrick, MD, FRCP(C), FSAR, Gary L. Brahm, MD, FRCP(C), Gevork N. Mnatzakanian, MD, FRCP(C), Casey Hurrell, PhD, Brian R. Herts, MD, Jeffery R. Bird, MD, FRCP(C) Canadian Association of Radiologists Journal Volume 70, Issue 2, Pages 125-133 (May 2019) DOI: 10.1016/j.carj.2019.03.002 Copyright © 2019 Canadian Association of Radiologists Terms and Conditions

Flowchart 1 Incidental renal mass on non-contrast CT. If the mass contains fat attenuation (<–10 HU), proceed to Flowchart 6. If prior studies are available for comparison, indeterminate masses with no change in imaging features for at least 5 years can be considered clinically insignificant. CT = computed tomography; MR = magnetic resonance; TSTC = too small to characterize; WO&W = without and with. *Ultrasound if the radiologist believes that there is a chance at successful characterization based on lesion appearance, location, and patient body habitus. Canadian Association of Radiologists Journal 2019 70, 125-133DOI: (10.1016/j.carj.2019.03.002) Copyright © 2019 Canadian Association of Radiologists Terms and Conditions

Flowchart 2 Incidental renal mass on contrast-enhanced CT. If the mass contains fat attenuation (<–10 HU), proceed to Flowchart 6. If prior studies are available for comparison, indeterminate masses with no change in imaging features for at least 5 years can be considered clinically insignificant. CT = computed tomography; MR = magnetic resonance; TSTC = too small to characterize; WO&W = without and with. *Ultrasound if the radiologist believes that there is a chance at successful characterization based on lesion appearance (suspected complex cyst), location, and patient body habitus. Canadian Association of Radiologists Journal 2019 70, 125-133DOI: (10.1016/j.carj.2019.03.002) Copyright © 2019 Canadian Association of Radiologists Terms and Conditions

Flowchart 3 Incidental renal mass on ultrasound. See Table 1 for Bosniak classification system. If prior studies are available for comparison, indeterminate masses with no change in imaging features for at least 5 years can be considered clinically insignificant. AML = angiomyolipoma; CT = computed tomography; MR = magnetic resonance; MRI = MR imaging; RCC = renal cell carcinoma; U/S = ultrasound; WO&W = without and with. *Radiologists may preferentially investigate with MRI or limited non-contrast renal CT first to evaluate for macroscopic fat in younger patients. Canadian Association of Radiologists Journal 2019 70, 125-133DOI: (10.1016/j.carj.2019.03.002) Copyright © 2019 Canadian Association of Radiologists Terms and Conditions

Flowchart 4 Incidental cystic renal mass. See Table 1 for Bosniak classification system. CT = computed tomography; MR = magnetic resonance; U/S = ultrasound; WO&W = without and with. *Ultrasound if the radiologist believes that there is a chance at successful characterization based on lesion appearance, location, and patient body habitus. Canadian Association of Radiologists Journal 2019 70, 125-133DOI: (10.1016/j.carj.2019.03.002) Copyright © 2019 Canadian Association of Radiologists Terms and Conditions

Flowchart 5 Incidental solid mass or mass too small to characterize. CT = computed tomography; MR = magnetic resonance; TSTC = too small to characterize; WO&W = without and with. *Ultrasound if the radiologist believes that there is a chance at successful characterization based on lesion appearance, location, and patient body habitus. Canadian Association of Radiologists Journal 2019 70, 125-133DOI: (10.1016/j.carj.2019.03.002) Copyright © 2019 Canadian Association of Radiologists Terms and Conditions

Flowchart 6 Incidental renal mass containing fat. CT = computed tomography; MR = magnetic resonance; WO&W = without and with. *The need for radiologic follow-up of angiomyolipomas < 4.0 cm is questionable, but it is recommended that radiologists discuss preferred management with their local urologist, as some feel that a period of active surveillance may be warranted to exclude a mass demonstrating significant growth. Canadian Association of Radiologists Journal 2019 70, 125-133DOI: (10.1016/j.carj.2019.03.002) Copyright © 2019 Canadian Association of Radiologists Terms and Conditions