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Whole-tissue biopsy phenotyping of three-dimensional tumours reveals patterns of cancer heterogeneity

Tanaka Nobuyuki, Kanatani Shigeaki, Tomer Raju, Sahlgren Cecilia, Kronqvist Pauliina, Kaczynska Dagmara, Louhivuori Lauri, Kis Lorand, Lindh Claes, Mitura Przemysław, Stepulak Andrzej, Corvigno Sara, Hartman Johan, Micke Patrick, Mezheyeuski Artur, Strell Carina, Carlson Joseph W., Fernández Moro Carlos, Dahlstrand Hanna, Östman Arne, Matsumoto Kazuhiro, Wiklund Peter, Oya Mototsugu, Miyakawa Ayako, Deisseroth Karl, Uhlén Per

Nature Biomedical Engineering 1 （ 10 ） 796 - 806 2017年10月

Intratumoral heterogeneity is a critical factor when diagnosing and treating patients with cancer. Marked differences in the genetic and epigenetic backgrounds of cancer cells have been revealed by advances in genome sequencing, yet little is known about the phenotypic landscape and the spatial distribution of intratumoral heterogeneity within solid tumours. Here, we show that three-dimensional light-sheet microscopy of cleared solid tumours can identify unique patterns of phenotypic heterogeneity, in the epithelial-to-mesenchymal transition and in angiogenesis, at single-cell resolution in whole formalin-fixed paraffin-embedded (FFPE) biopsy samples. We also show that cleared FFPE samples can be re-embedded in paraffin after examination for future use, and that our tumour-phenotyping pipeline can determine tumour stage and stratify patient prognosis from clinical samples with higher accuracy than current diagnostic methods, thus facilitating the design of more efficient cancer therapies.

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Factors influencing the operating time for single-port laparoscopic radical nephrectomy

Matsumoto Kazuhiro, Miyajima Akira, Fukumoto Keishiro, Komatsuda Akari, Niwa Naoya, Hattori Seiya, Takeda Toshikazu, Kikuchi Eiji, Asanuma Hiroshi, Oya Mototsugu

Japanese Journal of Clinical Oncology 47 （ 10 ） 976 - 980 2017年10月

ISSN 0368-2811

Objective: It is considered that laparoscopic single-site surgery should be performed by specially trained surgeons because of the technical difficulty in using special instruments through limited access. We investigated suitable patients for single-port laparoscopic radical nephrectomy, focusing on the anatomy and distribution of the renal artery and vein. Methods: This retrospective study was conducted in 52 consecutive patients who underwent single-port radical nephrectomy by the transperitoneal approach. In patients undergoing right nephrectomy, a 2-mm port was added for liver retraction. We retrospectively re-evaluated all of the recorded surgical videos and preoperative computed tomography images. The pneumoperitoneum time (PT) was used as an objective index of surgical difficulty. Results: The PT was significantly shorter for right nephrectomy than left nephrectomy (94 vs. 123 min, P = 0.004). With left nephrectomy, dissection of the spleno-renal ligament to mobilize the spleen medially required additional time. Also, the left renal vein could only be divided after securing the adrenal, gonadal and lumbar veins. In patients whose renal artery was located cranial to the renal vein, PT tended to be longer than in the other patients (131 vs. 108 min, P = 0.070). In patients with a superior renal artery, the inferior renal vein invariably covered the artery and made it difficult to ligate the renal artery via the umbilical approach at the first procedure. Conclusions: These findings indicate that patients undergoing right nephrectomy in whom the renal artery is not located cranial to the renal vein are suitable for single-port laparoscopic radical nephrectomy.

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Factors influencing the operating time for single-port laparoscopic radical nephrectomy: Focus on the anatomy and distribution of the renal artery and vein

Kazuhiro Matsumoto, Akira Miyajima, Keishiro Fukumoto, Akari Komatsuda, Naoya Niwa, Seiya Hattori, Toshikazu Takeda, Eiji Kikuchi, Hiroshi Asanuma, Mototsugu Oya

Japanese Journal of Clinical Oncology （OXFORD UNIV PRESS） 47 （ 10 ） 976 - 980 2017年10月

ISSN 0368-2811

© The Author 2017. Published by Oxford University Press. All rights reserved. Objective: It is considered that laparoscopic single-site surgery should be performed by specially trained surgeons because of the technical difficulty in using special instruments through limited access. We investigated suitable patients for single-port laparoscopic radical nephrectomy, focusing on the anatomy and distribution of the renal artery and vein. Methods: This retrospective study was conducted in 52 consecutive patients who underwent single-port radical nephrectomy by the transperitoneal approach. In patients undergoing right nephrectomy, a 2-mm port was added for liver retraction. We retrospectively re-evaluated all of the recorded surgical videos and preoperative computed tomography images. The pneumoperitoneum time (PT) was used as an objective index of surgical difficulty. Results: The PT was significantly shorter for right nephrectomy than left nephrectomy (94 vs. 123 min, P = 0.004). With left nephrectomy, dissection of the spleno-renal ligament to mobilize the spleen medially required additional time. Also, the left renal vein could only be divided after securing the adrenal, gonadal and lumbar veins. In patients whose renal artery was located cranial to the renal vein, PT tended to be longer than in the other patients (131 vs. 108 min, P = 0.070). In patients with a superior renal artery, the inferior renal vein invariably covered the artery and made it difficult to ligate the renal artery via the umbilical approach at the first procedure. Conclusions: These findings indicate that patients undergoing right nephrectomy in whom the renal artery is not located cranial to the renal vein are suitable for single-port laparoscopic radical nephrectomy.

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Ra-223 SPECT for semi-quantitative analysis in comparison with Tc-99m HMDP SPECT: phantom study and initial clinical experience

大家基嗣

EJNMMI RESEARCH （SPRINGER HEIDELBERG） 7 （ 1 ） 976 - 980 2017年10月

研究論文（学術雑誌）, ISSN 2191-219X

BACKGROUND: Image-based measurement of absorbed dose of Ra-223 dichloride may be useful in predicting therapeutic outcome in patients with castration-resistant prostate cancer (CRPC). In general, SPECT has been found to be more accurate than planar imaging in terms of lesion-based analysis. The aims of this study were to assess the feasibility and clinical usefulness of Ra-223 SPECT. The energy spectrum of Ra-223 and SPECT images of a cylindrical phantom with a hot rod were obtained to determine the collimator candidates and energy window settings suitable for clinical Ra-223 SPECT (basic study A). Another phantom with a tube-shaped chamber and two spheres simulating bowel activity and metastatic lesions in the lumbar spine was scanned with medium-energy general-purpose (MEGP) and high-energy general-purpose (HEGP) collimators (basic study B). Ten patients with CRPC underwent SPECT imaging 2 h after Ra-223 injection successively with MEGP and HEGP collimators in random order for 30 min each. Lesion detectability and semi-quantitative analyses of bone metastasis (i.e. lesion-to-background ratio (LBR)) were performed compared to Tc-99m HMDP SPECT. RESULTS: Basic study A revealed that an 84-keV photopeak ± 20% using the HEGP collimator offers better SPECT image quality than the other imaging conditions. Basic study B showed that uptake in one of the spheres was overestimated by overlapped activity of the tube-shaped chamber in planar imaging whereas the spheres had similar counts and significantly higher sphere-to-background ratio in SPECT. On both planar and SPECT images, HEGP gave higher image contrast than MEGP (p < 0.01). In the clinical study, Ra-223 SPECT at 84 keV ± 20% depicted more lesions with the HEGP than with the MEGP collimator (51 vs 36, p = 0.013). There was a positive correlation between LBR in Tc-99m SPECT and in Ra-223 SPECT (r = 0.67 with the MEGP and 0.69 with the HEGP collimator, p < 0.01). LBRs were significantly higher with the HEGP than with the MEGP collimator (p < 0.01). CONCLUSIONS: We recommended the use of the HEGP collimator at 84 keV ± 20% for Ra-223 SPECT imaging. Lesion-based semi-quantitative analysis in the human study revealed a good correlation between Ra-223 and Tc-99m HMDP SPECT in the early phase (2-3 h post injection).

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Angiogenic, inflammatory and immunologic markers in predicting response to sunitinib in metastatic renal cell carcinoma

大家基嗣

CANCER SCIENCE 108 （ 9 ） 1858 - 1863 2017年09月

研究論文（学術雑誌）, ISSN 1349-7006

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Prognostic significance of erythrocyteproteinband 4.1-like5 expression in upper urinary tract urothelial carcinoma

大家基嗣

UROLOGIC ONCOLOGY-SEMINARS AND ORIGINAL INVESTIGATIONS 35 （ 9 ） 2017年09月

研究論文（学術雑誌）, ISSN 1078-1439

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Simple and practical nomograms for predicting the stone-free rate after shock wave lithotripsy in patients with a solitary upper ureteral stone

大家基嗣

WORLD JOURNAL OF UROLOGY 35 （ 9 ） 1455 - 1461 2017年09月

研究論文（学術雑誌）, ISSN 0724-4983

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Guidelines for treatment of renal injury during cancer chemotherapy 2016

Horie S., Oya M., Nangaku M., Yasuda Y., Komatsu Y., Yanagita M., Kitagawa Y., Kuwano H., Nishiyama H., Ishioka C., Takaishi H., Shimodaira H., Mogi A., Ando Y., Matsumoto K., Kadowaki D., Muto S.

Clinical and Experimental Nephrology （Clinical and Experimental Nephrology） 22 （ 1 ） 1 - 35 2017年08月

研究論文（学術雑誌）, 共著, ISSN 1342-1751

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Cost analysis of leuprorelin acetate in Japanese prostate cancer patients

Goto Rei, Uda Akihito, Hiroi Shinzo, Iwasaki Kosuke, Takashima Kenta, Oya Mototsugu

Journal of Medical Economics 1 - 8 2017年08月

ISSN 1369-6998

Aims: This study aimed to evaluate the economic value for leuprorelin acetate 6-month depot compared with leuprorelin acetate 3-month depot from a societal perspective in Japanese prostate cancer patients. Methods: The cost analysis estimated the reduction in direct and indirect costs as well as intangible costs saved by having one less injection. Claims data were used for the analyses of direct and indirect costs reduction. A discrete choice experiment based on a web-based survey estimated the monetary value of the intangible costs for one injection. Another web-based survey of prostate cancer patients, who had received treatment with leuprorelin acetate injections, was carried out to calibrate the results of the discrete choice experiment. Results: Reductions in medical costs and loss of productivity for having one less injection in prostate cancer patients receiving leuprorelin acetate were JPY 5,670 and JPY 1,723, respectively. Intangible costs saved by using a 6-month depot formulation instead of a 3-month depot formulation for the injection of leuprorelin acetate were estimated to be JPY 19,872, including the values for a reduction in pain (JPY 3,131), injection site reactions (JPY 11,545), waiting time (JPY 9,479), and subtracting the value of medical consultation (JPY 4,283). The total cost reduction for having one less injection was JPY 27,265. Limitations: The respondents from the internet panel provided by a survey company are not necessarily a representative population of Japanese society. Conclusions: Leuprorelin acetate 6-month depot has an advantage in monetary value in the reduction in medical costs, loss of productivity, and intangible costs for having one less injection in prostate cancer patients compared with leuprorelin acetate 3-month depot. In the costs for treating with leuprorelin acetate, the percentage of intangible costs might not be negligible. The intangible costs will probably be actively evaluated to proceed to patient-centered healthcare in society.

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Obstructive azoospermia caused by low ligation of varicocele

Hagiuda Jun, Ishikawa Hiromichi, Hagiwara Masayuki, Kono Hidaka, Nakagawa Ken, Oya Mototsugu

Systems Biology in Reproductive Medicine 1 - 2 2017年08月

ISSN 1939-6368

Varicocele is commonly observed in male partners of infertile couples. The surgical ligation of varicoceles under microscopy can be safely performed by a skilled andrologist with most patients subsequently experiencing an improvement in semen quality. This is the first case in which obstructive azoospermia occurred after high inguinal varicocelectomy. The vas deferens was disrupted near the internal inguinal ring by fibrous tissue. A vasovasostomy was performed and semen parameters subsequently recovered.

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IJU this issue

Oya Mototsugu

International Journal of Urology 24 （ 8 ） 2017年08月

ISSN 0919-8172

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Increased vasohibin-1 expression is associated with metastasis and poor prognosis of renal cell carcinoma patients

Mikami Shuji, Oya Mototsugu, Kosaka Takeo, Mizuno Ryuichi, Miyazaki Yasumasa, Sato Yasufumi, Okada Yasunori

Laboratory Investigation 97 （ 7 ） 854 - 862 2017年07月

ISSN 0023-6837

The microvascular density detected by markers of endothelial cells (ECs), such as CD31 and CD34, is considered to be a biomarker for angiogenesis, and it is generally associated with the malignant potential of solid tumors. However, there is a conflicting relationship between the microvascular density and prognosis in clear-cell renal cell carcinoma (ccRCC) patients. It may be explained by the suggestion that the microvascular density cannot fully reflect the angiogenic activity in ccRCC, as the markers of ECs are expressed by both quiescent and activated ECs. To investigate the real angiogenic activity, we examined vasohibin-1 (VASH1), a recently identified regulator of angiogenesis, which was demonstrated to be specifically expressed by ECs of newly formed blood vessels. Expression of VASH1 and CD34 were immunohistochemically examined in 116 primary untreated ccRCCs, 10 metastatic untreated ccRCCs, and 9 metastatic ccRCCs treated with sunitinib. ECs in the tumor microvessels were sporadically immunostained for VASH1, although no VASH1 staining was observed in the non-neoplastic renal tissues. CD34 was ubiquitously expressed by all ECs in both ccRCC and non-neoplastic renal tissues. Multivariate Cox analysis indicated that an elevated VASH1 density, but not microvascular density, was a significant and independent predictor of overall survival (odds ratio, 7.71; P=0.003). The microvascular density was significantly decreased in the sunitinib-treated metastases compared with untreated tumors (P=0.001). On the other hand, the VASH1 density was significantly higher in the metastatic ccRCCs treated with sunitinib compared with non-treated ones (P=0.010), indicating that VASH1 may be associated with the resistance of ECs to sunitinib treatment. Thus, VASH1 expression may reflect the actual activity of angiogenesis, and VASH1 can serve as a new prognostic and predictive biomarker in patients with ccRCC.

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Nivolumab versus everolimus in advanced renal cell carcinoma

Tomita Yoshihiko, Fukasawa Satoshi, Shinohara Nobuo, Kitamura Hiroshi, Oya Mototsugu, Eto Masatoshi, Tanabe Kazunari, Kimura Go, Yonese Junji, Yao Masahiro, Motzer Robert J., Uemura Hirotsugu, Brent McHenry M., Berghorn Elmer, Ozono Seiichiro

Japanese Journal of Clinical Oncology 47 （ 7 ） 639 - 646 2017年07月

ISSN 0368-2811

Background: Nivolumab improved overall survival (OS) and objective response rate (ORR) versus everolimus in previously treated patients with advanced renal cell carcinoma in the phase III CheckMate 025 study (minimum follow-up: 14 months). We report efficacy and safety in the global and Japanese populations (minimum follow-up: 26 months).Methods: Patients were randomized 1:1 to receive nivolumab 3 mg/kg intravenously every 2 weeks or everolimus 10-mg tablet orally once daily. Primary endpoint: OS, key secondary endpoints: ORR, progression-free survival and safety. Results: Of 410 (nivolumab) and 411 (everolimus) patients, 37 (9%) and 26 (6%), respectively, were Japanese. Median OS for the global population was 26.0 months (nivolumab) and 19.7 months (everolimus; hazard ratio 0.73 [95% confidence interval [CI]: 0.61-0.88]; P = 0.0006), with medians not reached for Japanese patients. ORR for the global population was 26% (nivolumab) versus 5% (everolimus; odds ratio 6.13; 95% CI: 3.77-9.95); ORR for Japanese patients: 43% versus 8% (odds ratio 9.14; 95% CI: 1.76-88.33). In Japanese patients, any-grade treatment-related adverse events (AEs) occurred in 78% (Grade 3-4, 19%; most common, anemia [5%]) treated with nivolumab and 100% (Grade 3-4, 58%; most common, hypertriglyceridemia [12%]) treated with everolimus; the most common with nivolumab was diarrhea (19%) and with everolimus was stomatitis (77%). Quality of life was stable in the nivolumab arm. Conclusions: With >2 years of follow-up, Japanese patients had a higher response rate with nivolumab versus everolimus that was more pronounced yet consistent with the global population, with median OS not reached, and a favorable safety profile.

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Impact of baseline visceral fat accumulation on prognosis in patients with metastatic renal cell carcinoma treated with systemic therapy

大家基嗣

MEDICAL ONCOLOGY 34 （ 4 ） 37 - 46 2017年04月

研究論文（学術雑誌）, ISSN 1357-0560

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Determining When to Stop Prostate Specific Antigen Monitoring after Radical Prostatectomy

Matsumoto Kazuhiro, Komatsuda Akari, Yanai Yoshinori, Niwa Naoya, Kosaka Takeo, Mizuno Ryuichi, Kikuchi Eiji, Miyajima Akira, Oya Mototsugu

Journal of Urology 197 （ 3 ） 655 - 661 2017年03月

ISSN 0022-5347

Purpose We analyzed long-term followup data after radical prostatectomy to determine how long we should follow patients in whom the serum prostate specific antigen level measured by an ultrasensitive assay was consistently low. Materials and Methods We retrospectively reviewed clinicopathological data for 582 consecutive patients who underwent open or laparoscopic radical prostatectomy between 1995 and 2004, excluding 4 patients who received adjuvant therapy. We stratified the patients according to prostate specific antigen at 3 and 5 years after surgery, and examined subsequent biochemical recurrence (elevation of prostate specific antigen to greater than 0.2 ng/ml) during followup. Mean followup was 9.7 years. Results At 3 years after surgery prostate specific antigen levels were measured by an ultrasensitive assay in 323 patients who had not experienced biochemical recurrence. In 187 patients with undetectable prostate specific antigen levels (less than 0.01 ng/ml) the 10 and 15-year biochemical recurrence-free survival rates were 99% and 96%, respectively. At 5 years after surgery prostate specific antigen was measured in 315 patients by the ultrasensitive assay. In 162 patients with undetectable prostate specific antigen levels the 10 and 15-year biochemical recurrence-free survival rates were both 100%. In this group the prostate specific antigen level at last followup was less than 0.01 ng/ml in 132 patients, 0.01 to 0.03 ng/ml in 27 patients, and 0.06 ng/ml, 0.07 ng/ml and 0.11 ng/ml in 1 patient each. Conclusions This long-term review indicates that if patients have continuously undetectable prostate specific antigen levels by an ultrasensitive assay for 5 years, prostate specific antigen monitoring can be stopped with an extremely low risk of subsequent biochemical recurrence.

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Prolonged pneumoperitoneum time is an independent risk factor for intravesical recurrence after laparoscopic radical nephroureterectomy in upper tract urothelial carcinoma

大家基嗣

SURGICAL ONCOLOGY-OXFORD 26 （ 1 ） 73 - 79 2017年03月

研究論文（学術雑誌）, ISSN 0960-7404

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Simple and practical nomograms for predicting the stone-free rate after shock wave lithotripsy in patients with a solitary upper ureteral stone

Niwa Naoya, Matsumoto Kazuhiro, Miyahara Makoto, Omura Minami, Kobayashi Hiroaki, Kikuchi Eiji, Miyajima Akira, Miyata Kazutoyo, Oya Mototsugu

World Journal of Urology 1 - 7 2017年02月

ISSN 0724-4983

Purpose: To develop practical nomograms for predicting the stone-free rate after shock wave lithotripsy (SWL) in patients with a solitary stone in the proximal ureter. Methods: Between July 2006 and June 2015, 319 patients with a proximal ureteral stone who underwent preoperative non-contrast enhanced computed tomography (NCCT) and subsequently received SWL were identified. Patients’ age, gender, laterality, stone size, mean and maximum Hounsfield Unit (HU) of the stone, and skin-to-stone distance (SSD) were assessed. The stone-free status was defined as no radiopacity detected on the 3-month follow-up plain radiography or NCCT. Results: Mean stone size was 10 mm (range 3–20 mm). Mean and maximum HU of the stone ranged from 115 to 1447 (mean 701) and from 265 to 1881 (mean 1062), respectively. The overall stone-free rate was 70%. Multivariate analyses identified stone size (p < 0.001), maximum HU (p < 0.001), and SSD at 90° (p = 0.038) as independent predictive factors for the stone-free status after SWL. Nomograms could be constructed for predicting the probability of stone-free status after SWL corresponding to SSD of 8, 10, and 12 cm using maximum HU and stone size. Conclusions: This study demonstrated that stone size, maximum HU of the stone, and SSD at 90° are significant predictors of successful SWL outcome in patients with a proximal ureteral stone. We have developed simple and practical nomograms corresponding to three different SSDs for predicting the stone-free rate after SWL.

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Natural course of asymptomatic abnormal prostate findings incidentally detected by CT after intravesical BCG therapy

Matsushima Masashi, Kikuchi Eiji, Akita Hirotaka, Miyajima Akira, Oya Mototsugu, Jinzaki Masahiro

International Journal of Clinical Oncology 1 - 9 2017年02月

ISSN 1341-9625

Background: Detailed information is not currently available on the incidence, natural course, and management of asymptomatic abnormal prostate findings incidentally detected by radiologic evaluations after BCG therapy for non-muscle-invasive bladder cancer patients. Methods: We identified 38 patients who were evaluated by contrast-enhanced CT scans before TUR-BT and after BCG therapy between 2006 and 2012. We evaluated the clinical courses of patients with abnormal radiologic findings of the prostate gland after BCG therapy. Results: Abnormal findings on CT scans were found in the prostate glands of 11 of the 38 patients examined (28.9%), none of whom exhibited any sign or symptom associated with prostatitis. Abnormal findings included a low attenuation area (n = 6, 15.8%), contrast enhancement (n = 3, 7.9%), and a low attenuation area and contrast enhancement in the prostate gland (n = 2, 5.3%). During the follow-up, abnormal prostate findings disappeared spontaneously in most cases without any anti-bacterial or anti-tuberculous drug treatments. No significant differences were observed in patient clinical backgrounds, with the exception of post-BCG prostate volumes, between patients with and without abnormal CT findings. Furthermore, no significant differences were noted in the incidence of the adverse effects of BCG therapy, tumor recurrence rates, or progression rates between patients with and without abnormal CT findings of the prostate gland after BCG therapy. Conclusions: Asymptomatic abnormal prostate findings incidentally detected by CT after BCG therapy are not rare, and these disappear over time during the follow-up period without any treatment.

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Somatic KCNJ5 mutation occurring early in adrenal development may cause a novel form of juvenile primary aldosteronism

Tamura Ai, Nishimoto Koshiro, Seki Tsugio, Matsuzawa Yoko, Saito Jun, Omura Masao, Gomez-Sanchez Celso E., Makita Kohzoh, Matsui Seishi, Moriya Nobukazu, Inoue Atsushi, Nagata Maki, Sasano Hironobu, Nakamura Yasuhiro, Yamazaki Yuto, Kabe Yasuaki, Mukai Kuniaki, Kosaka Takeo, Oya Mototsugu, Suematsu Sachiko, Nishikawa Tetsuo

Molecular and Cellular Endocrinology 441 134 - 139 2017年02月

ISSN 0303-7207

We report a case of non-familial juvenile primary aldosteronism (PA). Super-selective adrenal venous sampling identified less aldosterone production in the right inferior adrenal segment than others. Bilateral adrenalectomy sparing the segment normalized blood pressure and improved PA. Both adrenals had similar histologies, consisting of a normal adrenal cortex and aldosterone synthase-positive hyperplasia/adenoma. An aldosterone-driving KCNJ5 mutation was detected in the lesions, but not in the histologically normal cortex. After taking into account that the two adrenal glands displayed a similar histological profile, as well as the fact that hyperplastic lesions in both glands exhibited a common KCNJ5 mutation, we conclude that the specific mutation may have occurred at an adrenal precursor mesodermal cell, at an early stage of development; its daughter cells were mixed with non-mutant cells and dispersed into both adrenal glands, resulting into a form of the condition known as genetic mosaicism.

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Diagnosis of Renal Angiomyolipomas

Jinzaki Masahiro, Silverman Stuart G., Akita Hirotaka, Mikami Shuji, Oya Mototsugu

Seminars in Ultrasound, CT and MRI 38 （ 1 ） 37 - 46 2017年02月

ISSN 0887-2171

With the increasing discovery of small renal masses with cross-sectional imaging, there has been the concomitant rise in their treatment. With the intent of early curative surgery for a presumed renal cell carcinoma, many renal masses are being resected at surgery without a confirmed diagnosis. Many of them are benign, and some are angiomyolipomas. The diagnosis of renal angiomyolipoma using imaging is, therefore, is as important as ever. Although most, if not all angiomyolipomas with abundant fat are diagnosed readily, some have too little fat to be detected with imaging. This article reviews the current classification, imaging pitfalls, and diagnosis of angiomyolipoma with an emphasis on the fat-poor types. Proper imaging technique, a thorough search for fat, and the appropriate use of percutanoeus biopsy are all needed to eliminate the unnecessary treatment of these benign neoplasms.

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