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This study was conducted in order to assess the role\u00a0of MR imaging characteristics of HLRCC-associated cystic lesions for\u00a0distinguishing benign from malignant complex renal cysts in this patient\u00a0population.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>This IRB-approved retrospective study included 42 HLRCC\u00a0patients (mean age, 46 \u00b1 14 years; men: women, 22:20) with a pathogenic\u00a0FH germline variant with renal cysts on abdominal MRI. Between June\u00a02002 and May 2022 these patients underwent partial or radical\u00a0nephrectomy for surgical removal of 76 renal lesions suspicious for renal\u00a0carcinomas. Two abdominal radiologists independently reviewed the MRI\u00a0images of all lesions while blinded to the surgical pathology. The lesion\u00a0characteristics, including location, 3D dimensions, internal composition,\u00a0characteristics of the cyst wall, nodules, septations, enhancement patterns\u00a0in different series and restricted diffusion on ADC, and b-2000 series were\u00a0recorded.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>Out of the 76 histologically characterized renal lesions, 44 (58%)\u00a0were found to be benign and 32 (42%) were malignant. Malignant cystic\u00a0lesions had a significantly larger mean diameter (4.0 \u00b1 3.4 cm) compared to\u00a0benign lesions (1.8 \u00b1 2.1 cm, p = 0.002). Inter-reader agreement analysis\u00a0identified 12 imaging features with moderate agreement (\u03ba &gt;0.4).\u00a0Univariate analysis identified 8 significant predictors of malignancy:\u00a0\u201ccombined areas of enhancement on T1-weighted images during the\u00a0nephrogenic phase (the nephrogenic phase, occurring approximately 70\u00a0seconds after intravenous contrast injection)\u201d, \u201cendophytic\/exophytic\u00a0mass\u201d, \u201cpresence of a nodule\u201d, and \u201cnodule enhancement on T1\u00a0nephrogenic phase.\u201d The final multivariable model for Reader 1 achieved an\u00a0AUC of 0.86 and for reader 2 with an AUC of 0.91, indicating high\u00a0diagnostic accuracy. At a predicted\u2010probability threshold of 0.17 (point = 60), the nomogram identified all malignant lesions and would have spared 57% of\u00a0patients with benign cysts from unnecessary surgery.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusion<\/jats:title>\n                    <jats:p>Qualitative MRI features, including nodule presence,\u00a0enhancement patterns, and lesion size, effectively differentiate between\u00a0benign and malignant renal complex cysts in patients with HLRCC. The final\u00a0multivariable model achieved high diagnostic, highlighting the potential of\u00a0MRI in guiding clinical decision-making and improving management of\u00a0cystic renal lesions in this high-risk population.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Graphical abstract<\/jats:title>\n                    <jats:p>\n                      Created in BioRender. Sheikhy, A. 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