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Renal mass biopsy — a practical and clinicopathologically relevant approach to diagnosis

Nature Reviews Urology volume 22, pages 8–25 (2025)Cite this article

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Abstract

Advancements in imaging modalities have increased the frequency of renal mass discovery. Imaging has typically been considered sufficient to guide management for a large proportion of these tumours, but renal mass biopsies (RMBs) have an increasing role in determining malignancy and can be a valuable tool for preventing unnecessary surgery in patients with benign tumours. A structured approach should be used to help to navigate the expanding repertoire of renal tumours, many of which are molecularly defined. In terms of tumour subtyping, the pathologist’s strategy should focus on stratifying patients into clinically different prognostic groups according to our current knowledge of tumour behaviour, including benign, low-grade or indolent, intermediate malignant or highly aggressive. Crucial pathological features and morphological mimicry of tumours can alter the tumour’s prognostic group. Thus, pathologists and urologists can use RMB to select patients with tumours at a reduced risk of progression, which can be safely managed with active surveillance within a tailored imaging schedule, versus tumours for which ablation or surgical intervention is indicated. RMB is also crucial in the oncological setting to distinguish between different high-grade tumours and guide tailored management strategies.

Key points

  • Renal mass biopsy (RMB) is a safe procedure that has a valuable role in the management of patients with small renal masses (cT1), as well as those with hereditary, advanced or metastatic disease.

  • RMB yields accurate pathological information that can reduce unnecessary surgical interventions for benign or indolent renal tumours, favour nephron-sparing surgery for tumours with malignant behaviour and guide patients with highly aggressive renal neoplasms to radical surgery or neoadjuvant therapy.

  • The increasing complexity of renal tumour classification is challenging to apply in clinical practice when tumours are classified according to their morphological and molecular features alone, without incorporation of prognostic outcomes.

  • A definitive diagnosis might not be absolutely crucial in RMB, but a diagnostic approach to stratifying renal neoplasms into the correct prognostic group is pivotal in ensuring correct management.

  • Pathologists need to be aware of overlapping features between well-recognized types of renal tumours and some of the rare and newly recognized renal cell carcinoma entities to avoid misdiagnosis and mismanagement.

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Fig. 1: Benign renal tumours and malignant morphological mimics.
Fig. 2: Oncocytic renal tumours.
Fig. 3: Main immunohistochemical markers that would help to differentiate oncocytic tumours within the various prognostic groups.
Fig. 4: High-grade morphology in renal mass biopsy.

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Authors and Affiliations

  1. Research Department of Pathology, UCL Cancer Institute, London, UK

    Hussein Mansour & Soha El Sheikh

  2. Specialist centre for kidney cancer, Royal Free London Hospital, London, UK

    My-Anh Tran-Dang, Miles Walkden, Ekaterini Boleti, Ravi Barod, Prasad Patki, Faiz Mumtaz, Maxine G. B. Tran, Axel Bex & Soha El Sheikh

  3. UCL Division of Surgery and Interventional Science, Rowland Street, London, UK

    Miles Walkden, Ravi Barod, Prasad Patki, Faiz Mumtaz, Maxine G. B. Tran & Axel Bex

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Contributions

H.M. researched data for the article. S.E.S. and A.B. contributed substantially to discussion of the content. S.E.S. and H.M. wrote the article. H.M., M.A.T.D., M.W., E.B., R.B., P.P., F.M., M.G.B.T. and A.B. reviewed and/or edited the manuscript before submission.

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Mansour, H., Tran-Dang, MA., Walkden, M. et al. Renal mass biopsy — a practical and clinicopathologically relevant approach to diagnosis. Nat Rev Urol 22, 8–25 (2025). https://doi.org/10.1038/s41585-024-00897-5

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