The Central Role of Imaging in Renal Cell Carcinoma: Insights into 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; however, it remains challenging due to overlapping imaging features and tumor complexity. CT is the most widely used imaging technique for renal mass evaluation, providing broad availability, high spatial resolution, and multiphasic acquisition capabilities. However, its ability to distinguish histologic subtypes and predict tumor aggressiveness remains limited. This review provides an updated overview of renal cell carcinoma epidemiology and evidence supporting CT as an essential imaging modality. It outlines key radiologic features of main histologic subtypes, highlights markers of aggressive behavior, and discusses the relationship between CT findings and the International Society of Urological Pathology (ISUP) grading system. We explore radiomics, summarizing its methodological foundations and applications in characterizing solid renal masses, emphasizing the need for multicenter studies and standardized radiomic workflows to develop accurate, reproducible tools for improving diagnostic accuracy and risk stratification for renal cell carcinoma.