What is the treatment approach for an elderly female patient with an incidental finding of a renal mass and a 4.4 cm ascending aortic aneurysm?

Management of Incidental Renal Mass in an Elderly Female Patient

For this elderly patient with an incidental renal mass, the immediate priority is obtaining multiphase contrast-enhanced CT or MRI to characterize the mass and determine if it represents a simple cyst, complex cyst, or solid tumor—this imaging is essential before any treatment decisions can be made. 1, 2

Immediate Diagnostic Workup for the Renal Mass

Obtain high-quality multiphase contrast-enhanced imaging immediately (CT or MRI with dedicated renal protocol) to assess: 1, 3

• Degree and pattern of contrast enhancement (>15-20 HU increase suggests solid mass) 1, 2
• Presence or absence of macroscopic fat (indicates benign angiomyolipoma if present) 1
• Internal complexity including septations, nodules, calcifications, or solid components 2, 4
• Anatomic relationships and clinical staging 1, 3

MRI demonstrates superior specificity compared to CT (68.1% vs 27.7%) for characterizing renal lesions and should be strongly considered. 1, 3

Obtain baseline laboratory studies: 1, 3

• Comprehensive metabolic panel with calculated GFR to assign CKD stage 1, 3
• Complete blood count 1, 3
• Urinalysis with proteinuria assessment 1, 3
• Chest imaging (chest X-ray or CT) for metastatic evaluation 1, 3

Risk Stratification Based on Imaging Characteristics

The management pathway depends entirely on what the imaging reveals:

Simple cysts (<20 HU on unenhanced CT, homogeneous, no enhancement): essentially 0% malignancy risk, require no further evaluation 4

Complex cystic masses require Bosniak classification: 2

• Bosniak IIF: ~10% malignancy risk, requires surveillance 2
• Bosniak III: ~50% malignancy risk, intervention typically indicated 2
• Bosniak IV: ~100% malignancy risk, intervention required 2

Solid masses: presumed malignant until proven otherwise, especially if enhancement is present 1, 2

Role of Renal Mass Biopsy

Strongly consider percutaneous renal mass biopsy before making treatment decisions in this elderly patient, as it has 97% sensitivity, 94% specificity, and 99% positive predictive value. 3 This is particularly important because:

• One-third of biopsied renal masses prove to be benign 1
• Biopsy results guide decision-making for active surveillance versus intervention 1
• In elderly patients with comorbidities, avoiding unnecessary surgery for benign lesions is critical 1

A nondiagnostic biopsy cannot be considered evidence of benignity—repeat biopsy should be performed if initial biopsy is nondiagnostic. 1, 2

Treatment Algorithm Based on Mass Characteristics

For Solid Masses or High-Risk Complex Cystic Masses:

If the mass is cT1a (<4 cm) and intervention is indicated: 1

• Partial nephrectomy is the standard of care to preserve renal function 1, 3
• Thermal ablation (radiofrequency or cryoablation) is an appropriate alternative for masses <3 cm, particularly in elderly, comorbid patients considered unfit for surgery 1
• Percutaneous approach is preferred for thermal ablation 1
• RMB should be performed prior to thermal ablation 1

If the mass is cT1b (4-7 cm): 3

• Partial nephrectomy remains the standard of care when technically feasible 3
• Radical nephrectomy may be considered if tumor location is unfavorable or patient has increased surgical risk 3
• Thermal ablation becomes less effective with higher complication rates at this size 2

For Small Solid Masses (<2 cm) in Elderly Patients:

Active surveillance is a viable and often preferred option when: 1, 5

• The anticipated risk of intervention or competing risks of death outweigh potential oncologic benefits 1
• Patient has significant comorbidities and limited life expectancy 1, 5
• Mean tumor growth rate is only 0.26-3 mm/year 1
• Progression to metastatic disease is rare (1-2%) 1

Surveillance protocol if active surveillance is chosen: 1

• Repeat imaging at 3 and 6 months initially 1
• Then every 6 months up to 3 years 1
• Annually thereafter 1
• Consider RMB for additional risk stratification 1

Critical Considerations for This Elderly Patient

Age and comorbidity status are paramount in decision-making. 1 The 2025 European Association of Urology guidelines specifically state that for elderly and comorbid patients with incidentally detected small renal masses, RCC-specific mortality is relatively low compared to significant competing-cause mortality. 1

Renal function preservation is critical: 1, 3

• Prioritize nephron-sparing approaches whenever possible 1, 3
• Consider nephrology referral if GFR <45, confirmed proteinuria present, or GFR expected to be <30 after intervention 1

Genetic counseling should be considered only if patient is ≤46 years old, which does not apply to this elderly patient. 1, 3

Management of the 4.4 cm Ascending Aortic Aneurysm

The ascending aortic aneurysm requires separate cardiothoracic surgical evaluation and monitoring as recommended by the CT report. This is a distinct cardiovascular issue that does not directly impact renal mass management but does factor into overall surgical risk assessment if intervention for the renal mass is being considered.

Key Clinical Pitfalls to Avoid

Do not assume any renal mass is benign without proper imaging characterization, as malignancy risk increases with size and complexity. 2

Avoid single-phase contrast-enhanced CT without an unenhanced phase, as this markedly limits characterization ability. 1, 2

Do not proceed directly to radical nephrectomy without considering nephron-sparing options, especially in elderly patients where renal function preservation impacts long-term survival. 1, 3

In elderly patients with significant comorbidities, do not automatically pursue aggressive intervention—active surveillance or expectant management may provide better quality of life outcomes. 1, 5