Enhanced staging of renal cell carcinoma using tumor morphology features: model development and multi-source validation

Preoperative detection of pT3a invasion in non-metastatic renal cell carcinoma (RCC) remains challenging with CT. This study developed and validated radiomic models using preoperative CT to identify pT3a invasions. Six models were trained and internally validated via nested cross-validation on 999 patients from one hospital. External validation included 313 patients from two hospitals and 204 patients from four TCIA datasets. A multi-reader multi-case study with seven radiologists evaluated the model's incremental value. The morphology model achieved the highest internal AUC (0.867, 95% CI: 0.866-0.869) and maintained performance in external validations (AUC = 0.895 and 0.842). When used as a second reader, it significantly improved junior radiologists' sensitivity and discrimination (AUC: 0.790 vs. 0.831, p < 0.001) without compromising specificity. This study demonstrates that CT-based radiomic models, particularly the morphology model, can reliably detect pT3a invasion and enhance diagnostic accuracy for junior radiologists, offering potential clinical utility in preoperative staging.