Warren, Hannah; (2025) Novel Imaging tests for the diagnosis and risk stratification of localised renal tumours. Doctoral thesis (Ph.D), UCL (University College London).

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Abstract

Background: Incidental renal tumours are rising due to expansion of cross-sectional imaging. Standard care for renal tumours is surgical excision. However 30% of such tumours are benign (mostly oncocytomas), and many more are low-risk for progression. A more selective use of surgery has been limited by a lack of trusted diagnostic tools and limited data on the natural history of incidental benign tumours. [99mTc]Tc-sestamibi SPECT/CT is an emerging non-invasive imaging modality to identify renal oncocytoma. Aims: 1) Report the accuracy of all diagnostic imaging modalities for early stage (clinical T-stage 1) renal tumours; 2) report the natural history of renal oncocytoma; 3) understand facilitators and barriers of diagnostic biopsy; 4) report the feasibility of recruitment to a multi-centre diagnostic accuracy study of [99mTc]Tc-sestamibi SPECT/CT. Methods: 1) A systematic review and meta-analysis of diagnostic accuracy of imaging modalities for renal tumours; 2) a systematic review and meta-analysis of the natural history of renal oncocytoma; 3) an international survey of clinicians and patients on use of biopsy for diagnosis and management of localised renal tumours; 4) a multi-centre feasibility diagnostic accuracy study of [99mTc]Tc-sestamibi SPECT/CT compared to histopathology for T1 renal tumours. Results: 1) [99mTc]Tc-sestamibi SPECT/CT is the diagnostic imaging test with strongest evidence base, with sensitivity of 88.6% (95% CI 82.7-92.6) and specificity of 77.0% (95% CI 63.0-86.9%) to detect malignant disease. 2) Incidence of metastases or death from untreated oncocytoma is 0% and there is no impact on renal function 3) Diagnostic biopsy is routine practice for a minority of clinicians, yet many patients express a preference to manage benign tumours conservatively. 4) Recruitment to a large, multi-centre diagnostic accuracy study of [99mTc]Tc-sestamibi SPECT/CT for T1 renal tumours is feasible without the need for significant additional training. Conclusion: The work presented in this thesis has shown that surveillance should be first-line treatment for renal oncocytoma. Pre-operative diagnosis is essential to rationalise surgery. Biopsy continues to face barriers that an imaging test could overcome. Of all imaging tests, [99mTc]Tc-sestamibi SPECT/CT appears to be the most actionable and a randomised clinical test-treat trial of a diagnostic pathway including [99mTc]Tc-sestamibi SPECT/CT compared to standard care is potentially practice changing.

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