Clear cell renal cell carcinoma

Case contributed by Ammar Ashraf
Diagnosis certain


Off and on right flank pain. No fever, dysuria or hematuria.

Patient Data

Age: 75 years
Gender: Female

A large exophytic lobulated heterogeneous solid mass lesion measuring 7.9 x 8.4 cm is depicted along the mid/lower pole of the right kidney. Small fluid echogenicity areas, likely representing necrosis, are seen within the center of this lesion. Some vascularity is seen in its peripheral part on Doppler ultrasound examination. Impression: Highly suspicious right renal mass lesion.

Findings: Large lobulated exophytic mass lesion measuring 10 x 8.8 x 8.5 cm is seen at the lower pole of the right kidney. Two tiny calcification foci are seen in it. It has an enhancing (non-contrast density=20 HU, Venous phase density=82 HU) peripheral solid component and non-enhancing irregular necrotic center. The mass is grossly extending beyond the renal capsule, has mild perinephric fat stranding. However, it is still confined within Gerota's fascia. Some prominent arteries & veins (neo-vascularity) are seen along the inferior aspect of this mass lesion. A prominent draining vein is seen at the inferior aspect of this mass, which is draining to the inferior vena cava via the right ovarian vein. The mass is compressing the lower pole calyceal system and the renal pelvis; however, no invasion/infiltration of the collecting system or hydronephrosis is seen. No clear signs of the adjacent renal vein or IVC thrombosis. No evidence of local or distant metastasis is seen.  

A small simple cyst is seen in either kidney.  Multiple focal radiolucent lesions with polka dot sign in the axial images are seen in the T11, T12, L1, and L2 vertebral bodies; these are likely vertebral hemangiomas.

Impression: Large heterogeneous right renal mass, suspicious of renal cell carcinoma.

Note: This is an old case. Unfortunately the "axial venous phase images" are not available.  

Case Discussion

Pre-operative diagnosis: Right renal tumor.

Procedure: Laparoscopic right nephrectomy.

Diagnosis: Clear cell renal cell carcinoma. Fuhrman nuclear grade 1.

Tumor size= 8 x 7.5 x 5 cm. Tumor is unifocal. Focal capsular invasion is seen. Margins (renal vessels, perinephric fat & ureter) are negative. No lymphovascular or perineural invasion seen. No adrenal gland identified. Background of focal chronic interstitial nephritis.

Pathologic staging:  T2a, Nx, Mx

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