e16517 Background: While active surveillance for small renal cell carcinoma (RCC) gained acceptance due to harmless behavior, controversy still continues on aggressive potential of small RCC. Despite small tumor size, there still remains a risk for distant metastasis and recurrence. The biology of small RCC, especially the risk factors for metastasis and recurrence, has not been fully elucidated. It is therefore important to evaluate the aggressive potential of small RCCs to ensure that necessary treatments are given, but also to avoid overtreatment. Therefore, we used bulk RNA sequencing and single cell RNA sequencing (scRNA-seq) to reveal genetic biomarkers and distinct immune microenvironment in aggressive small RCC patients. Methods: Five cases of T1a (≤ 4cm) clear cell RCCs (ccRCCs) that were reported to have synchronous metastasis or recurrence were identified as an aggressive group and four cases with age, sex, and tumor size-matched ccRCCs patients with no metastasis or recurrence were identified as a non-aggressive group among prospective cohort (ClinicalTrials.gov Identifier: NCT03694912) RCC database. For the control, two healthy kidney donors were enrolled. We performed scRNA-seq using the 10X Genomics platform and bulk analysis for the total eleven cases of peripheral blood mononuclear cell (PBMC) samples. We demultiplexed pooled 11 samples using Souporcell and sequencing reads were normalized and analyzed using R/Seurat package. Cellular components of each sample were determined based on known marker genes. Bulk analysis involved differential gene expression analysis and pathway enrichment analysis. Results: The mean tumor size and age was 2.6 cm and 63 years old, respectively. Among 5 aggressive ccRCC patients, two patients had synchronous lung metastasis and two patients had synchronous bone metastasis. One patient had recurrence after partial nephrectomy. We analyzed 36,303 cells and identified 31 cell subpopulations. Our single-cell analysis unveiled distinct variations in T cell and natural killer (NK) cell proportions among aggressive, non-aggressive, and normal groups, highlighting significant differences in these ratios. Additionally, a notable pattern of gene expression levels was found between non-aggressive and aggressive groups, with a substantial increase in the expression levels of GSTP, ASRG, and SNORD142 genes in aggressive group. Conclusions: As T1a ccRCCs present low but non-negligible risk of metastasis and recurrence, patients with small RCCs should be counseled on such risk when offered active surveillance. Patients with higher NK cells and lower naïve CD8+ T cell are associated with higher risk of metastasis and recurrence in T1a RCC. This study suggests a promising potential for leveraging genetic markers and immune cell dynamics in the diagnosis of aggressive ccRCC using non-invasive screening methods.