PURPOSE: The diagnostic differential for CD117/KIT(+) oncocytic renal tumor biopsies is limited to benign renal oncocytoma (RO) vs. chromophobe renal cell carcinoma (ChRCC), however further differentiation is often challenging and requires surgical resection. We investigated clinical variables that might improve preoperative differentiation of CD117(+) RO vs. ChRCC to avoid the need for benign tumor resection. EXPERIMENTAL DESIGN: 124 nephrectomy patients from a single institute with 133 RO or ChRCC tumors were studied. Patients from 2003-2012 comprised a retrospective cohort to identify clinical/radiographic variables associated with RO versus ChRCC. Prospective validation was performed among consecutive RO/ChRCC tumors resected from 2013-2017. RESULTS: Tumor size and younger age were associated with ChRCC, and multifocality with RO, however the most reliable variable for ChRCC vs. RO differentiation was the tumor:cortex peak early-phase enhancement ratio (PEER) using multiphase computer tomography (CT). Among 54 PEER-evaluable tumors in the retrospective cohort (19 CD117(+), 13 CD117(-), 22 CD117-untested), PEER classified each correctly as RO (PEER >0.50) or ChRCC (PEER <0.50), except four misclassified CD117(-) ChRCC variants. Prospective study of PEER confirmed 100% accuracy of RO/ChRCC classification among 22/22 additional CD117(+) tumors. Prospective inter-observer reproducibility was excellent for PEER scoring (intra-class correlation coefficient, ICC=0.97) and perfect for RO/ChRCC assignment (ICC=1.0). CONCLUSIONS: In the largest clinical comparison of RO vs. ChRCC to our knowledge, we identified and prospectively validated a reproducible radiographic measure that differentiates CD117(+) RO from ChRCC with potentially 100% accuracy. PEER may allow reliable biopsy-based diagnosis of CD117(+) RO, avoiding the need for diagnostic nephrectomy.
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