The Central Role of Imaging in Renal Cell Carcinoma: A Comprehensive Review of Tumor Aggressiveness, Histology, and Radiomics

Renal cell carcinoma encompasses a heterogeneous group of kidney tumors with wide variations in biological behavior, histologic subtype, and clinical aggressiveness. Accurate preoperative characterization is essential for management, yet remains challenging because benign, indolent, and aggressive lesions often show overlapping imaging features. CT is the most widely used modality for renal mass evaluation, offering broad availability, high spatial resolution, and multiphasic acquisition. This comprehensive narrative review summarizes current evidence on CT-based characterization of renal cell carcinoma, radiologic–pathologic correlation, imaging markers of tumor aggressiveness, renal mass biopsy, and radiomics. Radiomics and other quantitative imaging approaches may complement conventional imaging by capturing tumor heterogeneity and biologically relevant features; however, most studies remain retrospective, single-center, and methodologically heterogeneous. Multicenter validation, standardized acquisition and segmentation, transparent reporting, and demonstration of added clinical value are required before these methods can be implemented in routine care.