Pediatric cystic nephroma
Pediatric cystic nephromas, previously known as multilocular cystic nephromas, are rare benign renal neoplasms occurring in children. As of the 2016 WHO classification, they are considered distinct from adult cystic nephromas 1,2.
Evolving terminology regarding cystic nephromas and other cystic renal tumors reflects ongoing changes in classification, in step with shifting understanding of the disease processes and genetic aberrations.
Classically, cystic nephromas were thought to occur in a bimodal age distribution, affecting young children and adults in middle age. The generic term "multilocular cystic renal tumor" was sometimes used for either cystic nephroma or cystic partially differentiated nephroblastoma, as they were indistinguishable except by histologic analysis.
More recently, it has been established that the lesions arising in children are distinct from adult cystic nephromas on both immunohistochemical and genetic bases, and are separately categorized by WHO as pediatric cystic nephroma 1,2.
- overall rare
- pediatric (3 months to 4 years of age) - 75% male predilection
Pediatric cystic nephroma usually present as an asymptomatic palpable abdominal mass felt by parents, with increasing abdominal girth. It may also present with hematuria or possibly urinary tract infection.
Grossly, cystic nephroma are typically unifocal multiloculated cystic masses surrounded by a thick fibrous capsule and compressed parenchyma 3,4. Calcification, hemorrhage, and necrosis are unusual.
Microscopically, these tumors are lined by flat, cuboid, or hobnail cells 4, while the fibrous septa may contain mature tubules 5. As opposed to cystic partially differentiated nephroblastoma, the tumor septa contain no blastema cells.
Genetic analysis show a high prevalence (86%) of DICER1 gene mutations in pediatric cases, as compared to ~10% of adult cystic nephroma 2.
A familial association of cystic nephroma with the cystic type of pleuropulmonary blastoma related to DICER1 mutation has been described.
Pediatric cystic nephromas generally have the appearance of a multilocular cystic encapsulated mass on most modalities.
May present as a large abdominal mass displacing and effacing adjacent bowel loops.
- multilocular cystic mass originating from kidney 6
- claw or beak-shape of adjacent renal parenchyma (claw sign) may help confirm a renal origin
- cyst contents usually anechoic, but low-level echoes may be seen
- septal vascularity can also be seen 4
- multilocular cystic mass often herniates into the renal pelvis
- variable septal enhancement
- no nodular or solid enhancement 4
- +/- associated streakiness in perirenal fat 6
Signal characteristics include 4,6:
- T1: variable signal, depending on the protein or blood products of the cysts
- T2: hyperintense (cysts)
- T1 C+ (Gd): septal enhancement may be seen
Treatment and prognosis
Radical or partial nephrectomy is usually done, with lymph node excision.
It is often difficult to distinguish cystic Wilms tumor from pediatric cystic nephromas:
- solid nodular components in a tumor should arouse suspicion of Wilms tumor 8
- pediatric cystic nephroma tends to occur in younger children than Wilms tumors
Multicystic dysplastic kidney (MCDK) is a developmental anomaly in which the entire kidney is replaced by noncommunicating cysts of varying sizes. It is usually diagnosed prenatally or at birth, while multiloculated cystic renal tumors do not occur in the perinatal period 4. In addition, enhanced compressed renal parenchyma is seen to surround cystic nephroma on contrast-enhanced cross-sectional studies, while this tissue is absent in MCDK.
- 1. Moch H, Cubilla AL, Humphrey PA, Reuter VE, Ulbright TM. The 2016 WHO Classification of Tumours of the Urinary System and Male Genital Organs-Part A: Renal, Penile, and Testicular Tumours. (2016) European urology. 70 (1): 93-105. doi:10.1016/j.eururo.2016.02.029 - Pubmed
- 2. Li Y, Pawel BR, Hill DA, Epstein JI, Argani P. Pediatric Cystic Nephroma Is Morphologically, Immunohistochemically, and Genetically Distinct From Adult Cystic Nephroma. (2017) The American journal of surgical pathology. 41 (4): 472-481. doi:10.1097/PAS.0000000000000816 - Pubmed
- 3. Silver IM, Boag AH, Soboleski DA. Best cases from the AFIP: Multilocular cystic renal tumor: cystic nephroma. (2008) Radiographics : a review publication of the Radiological Society of North America, Inc. 28 (4): 1221-5; discussion 1225-6. doi:10.1148/rg.284075184 - Pubmed
- 4. Chung EM, Graeber AR, Conran RM. Renal Tumors of Childhood: Radiologic-Pathologic Correlation Part 1. The 1st Decade: From the Radiologic Pathology Archives. Radiographics. 2016;36 (2): 499-522. doi:10.1148/rg.2016150230 - Pubmed citation
- 5. Guermazi A. Imaging of kidney cancer. Springer Verlag. (2006) ISBN:3540211292. Read it at Google Books - Find it at Amazon
- 6. Silver IM, Boag AH, Soboleski DA. Best cases from the AFIP: Multilocular cystic renal tumor: cystic nephroma. Radiographics. 28 (4): 1221-5. doi:10.1148/rg.284075184 - Pubmed citation
- 7. Narayanasamy S, Krishna S, Prasad Shanbhogue AK, Flood TA, Sadoughi N, Sathiadoss P, Schieda N. Contemporary update on imaging of cystic renal masses with histopathological correlation and emphasis on patient management. (2019) Clinical radiology. 74 (2): 83-94. doi:10.1016/j.crad.2018.09.003 - Pubmed
- 8. Sanchez TR, Ducore J, Balagtas J et-al. WARM N COLD: malignant and benign renal tumors in children. Emerg Radiol. 2014;21 (3): 261-9. doi:10.1007/s10140-014-1202-8 - Pubmed citation