Evaluating Malignancy Detection in Small Renal Masses: Integrating the Pseudocapsule Into the Clear Cell Likelihood Score

Background Although the clear cell likelihood score ( ccLS ) v2.0 demonstrates high specificity for clear cell renal cell carcinoma ( ccRCC ), its performance to characterize general malignancy in small renal masses ( SRMs ) remains limited. Purpose To develop and validate a modified clear cell likelihood score (m‐ ccLS ) incorporating the pseudocapsule to improve malignancy detection in SRMs while preserving specificity for diagnosing ccRCC . Study Type This study was retrospective in type. Subjects 352 patients with pathologically proven SRMs were included: development ( n = 235), internal validation ( n = 60), and external validation ( n = 57). Field Strength/Sequence Imaging was performed at 3.0 and 1.5 T using fast spin‐echo T2‐weighted imaging, single‐shot echo planar diffusion‐weighted imaging, 3D spoiled gradient echo (GRE) T1‐weighted dynamic contrast‐enhanced imaging, and in‐ and opposed‐phase using T1‐weighted GRE. Assessment 14 radiologists blinded to histopathology independently evaluated each SRM using ccLS v2.0 and m‐ccLS scores in separate reading sessions; four, five, and five readers interpreted the development, internal, and external cohorts, respectively. Statistical Tests Random‐effects logistic regression, receiver operating characteristic curve, DeLong test, net reclassification improvement (NRI), integrated discrimination improvement (IDI), and Fleiss Kappa test were used. The statistical significance level was p < 0.05. Results For malignancy detection, m‐ ccLS showed a significantly higher area under the curve ( AUC ) than ccLS v2.0 across the development (0.850 vs. 0.772), internal validation (0.856 vs. 0.779), and external validation (0.803 vs. 0.720) cohorts with improved classification ( NRI = 0.270, 0.045, and 0.028) and discrimination ( IDI = 0.132, 0.206, and 0.120). For diagnosing ccRCC , m‐ ccLS and ccLS v2.0 showed similar results (0.908 vs. 0.894, p = 0.250; 0.912 vs. 0.898, p = 0.134; 0.865 vs. 0.838, p = 0.065) in development, internal, and external validation cohorts, respectively. m‐ ccLS category 3 contained fewer ccRCCs (33.3% vs. 72.5%; 15.8% vs. 47.2%; 7.6% vs. 26.9%) and malignancies (79.2% vs. 88.7%; 71.6% vs. 73.0%; 55.4% vs. 63.9%) than ccLS v2.0 category 3. Data Conclusion m‐ccLS improves malignancy detection in SRMs compared with ccLS v2.0 without impairing diagnostic performance for ccRCC. Evidence Level 4. Technical Efficacy Stage 2.