Using flow ratio of peritumoral artery/renal aorta from DSA imaging to predict high-risk clear cell renal cell carcinoma.

PURPOSE: The objective of this study was to evaluate the predictive value of the peritumoral artery-to-renal aorta flow ratio, derived from digital subtraction angiography, for identifying clear cell renal cell carcinoma at high risk of recurrence after nephrectomy.

METHODS

In this prospective study, patients undergoing radical or partial nephrectomy for clear cell renal cell carcinoma between May 2025 and December 2025 were enrolled. Three experienced radiologists calculated the arterial flow ratio from preoperative DSA images using a novel, dedicated software solution. We employed univariate and multivariate logistic regression to determine the association between this hemodynamic parameter and postoperative pathological classification of high-risk clear cell renal cell carcinoma.

RESULTS

Among the 100 included patients, a flow ratio cutoff of 0.039 identified 34 patients (34%) with a high ratio. A high flow ratio of peritumoral artery/renal aorta was strongly associated with a pathological diagnosis of high-risk clear cell renal cell carcinoma (66.67% vs. 25.32%, P < 0.001). High-risk tumors exhibiting a high flow ratio were also significantly more likely to present at an advanced pathological T stage (≥ T2) (47.37% vs. 5.26%, P < 0.001). Crucially, a high flow ratio was confirmed as an independent predictor of high-risk clear cell renal cell carcinoma on multivariate analysis (Odds Ratio: 9.809; 95% Confidence Interval: 1.928–49.895; P = 0.006).

CONCLUSION

The preoperative flow ratio of peritumoral artery/renal aorta, measured via DSA, is a significant and independent imaging biomarker associated with high-risk clear cell renal cell carcinoma. This novel parameter may aid in preoperative risk stratification.