Papillary renal cell carcinoma

Last revised by Ammar Ashraf on 30 Jun 2023

Papillary renal cell carcinomas (pRCC) are the second most common histological subtype of renal cell carcinoma (RCC).

This subtype may account 13-20% of all renal cell cancer 1. This subtype is also the most common in the renal transplant population 11. There is slightly increased male predilection. 

As with other types of renal cell cancer, most are asymptomatic and incidentally discovered.

There are two subtypes described according to morphology 7:

  • type I
    • have papillae covered by a single layer of cuboidal or low columnar cells with scanty cytoplasm and low-grade nuclei
    • carry a better prognosis than type II tumors
  • type II:
    • are of a higher nuclear grade and contain more than one layer of cells with abundant eosinophilic cytoplasm
    • although mostly unilateral, this subtype is considered the most common to result in bilateral renal cell cancers 1

While it has been described to have a tendency to present at a lower stage, it still has a distinct potential for progression and aggressive behavior 4.

Although there is no absolute rule, in general, papillary renal cancers at diagnosis tend to have a smaller mean diameter and be at a lower stage. The imaging features of type 1 and type 2 tumors may overlap.

Generally tends to be hypoechoic on ultrasound 9.

Smaller lesions tend to be homogeneous in attenuation with larger tumors tending to be heterogeneous.

These tumors are characteristically less vascularized than the more common clear cell subtype, showing overall hypoenhancement compared to the adjacent normal renal cortex, particularly seen in the corticomedullary phase.

When not enhancing at all, it can be difficult to differentiate from hyper-attenuating cysts 8

The tumors generally present with a pseudo-capsule. 

  • T1: hypointense
  • T2: hypointense
  • T1 C+ (Gd): contrast enhancement tends to be less intense than in the more common clear cell RCC subtype
  • DWI: restricted diffusion may be useful for differentiating from a hemorrhagic cyst

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Cases and figures

  • Case 1: type 2
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  • Case 2
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  • Case 3
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  • Case 4
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  • Case 5: synchronous renal and colonic carcinomas
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  • Case 6: in a patient with acute appendicitis
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  • Case 7: type 1
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  • Case 8: pT3
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  • Case 9: type 1
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  • Case 10: type 2
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  • Case 11: synchronous ipsilateral pRCC of the kidney and TCC of the renal pelvis
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