Renal cell carcinoma

Case contributed by Dr Bruno Di Muzio

Presentation

Abdominal pain. Jaundice.

Patient Data

Age: 67-year-old

MRCP

Modality: MRI

Multiple multifaceted stones are demonstrated within the common bile duct. The largest of these measures 1.3 x 1.3 cm and causes bile duct dilatation proximally. The common bile duct measures up to 1.4 cm. At least two further stones are seen proximal to this, and at least a further three stones distal to this. The gallbladder contains numerous stones and sludge. 

Note is made of a low insertion of the cystic duct. Mild intrahepatic bile duct dilatation is observed. No focal liver lesion. The pancreas appears atrophic with no pancreatic duct dilatation. 

There is a right sided cortical renal mass lesion measuring 6.3 x 5.0 cm, containing elements of blood. Appearances are most suspicious for a renal cell carcinoma. Left parapelvic renal cyst. Normal adrenals. No para-aortic nodes. 

CT Abdomen and pelvis

Modality: CT

A heterogeneous mass measuring 6.8 x 5.6 x 6.3mcm arises from the posterior aspect of the mid part of the right kidney. Normal enhancement of the right renal vein and IVC. No lymph node enlargement. A 6mm well defined low-density lesion is seen in the lower pole of the left kidney. It is too small to characterise. Multiple small gall stones. A stent is seen extending from the left intrahepatic ducts into the duodenum. Minor duct dilatation. Minor duct air. The liver, spleen, pancreas adrenal glands are normal. The lungs and pleural spaces are clear. No suspicious bony lesion. 

Case Discussion

Imaging features of Impression choledocholithiasischolelithiasis, and right renal cell carcinoma. The patient was submitted to a cholecystectomy and right nephrectomy: 

MACROSCOPIC DESCRIPTION: A radical nephrectomy specimen comprises kidney, perirenal fat up to 40mm in thickness, and a short segment of the proximal ureter. Based on the cortex at the midpoint is a widely necrotic, soft pale orange tan tumour. Only approximately 1/3 of the tumour is within the kidney. Most of it is located within the perirenal fat posteriorly and laterally. However, there is no convincing evidence of true fat invasion, as the perirenal fat strips easily from the tumour surface, to reveal a glistening intact capsule separating from the tumour. The tumour is located at least 20mm from the inked fat margin laterally, and at least 5mm from the inked fat margin posteriorly. The tumour bulges into but does not definitely invade hilar fat. No renal vein invasion is identified. The uninvolved parenchyma appears unremarkable. No adrenal gland is included.

MICROSCOPIC DESCRIPTION: The sections of kidney show a densely hypercellular tumour. This is composed of well-formed papillary structures, the majority of which are covered by a single layer of moderately atypical epithelial cells. These have round and oval vesicular nuclei, some with prominent nucleoli and a variable amount of pale eosinophilic cytoplasm. In some areas, there is a stratified arrangement of the papillary epithelium. Occasional small collections of macrophages are noted within papillae cores. A rare gland-like structure containing mucinous/myxoid material is also noted. No mitotic figures are seen. There is extensive central necrosis within the tumour. The tumour bulges into perinephric adipose tissue but is separated from this by a fibrous capsule of varying thickness. The tumour has a sharp interface with adjacent renal parenchyma. No evidence of vascular invasion is seen. The features are of papillary renal cell carcinoma type 1. A section through renal hilar vessels and the ureter is free of tumour.

The section of gallbladder shows moderate chronic inflammation within the lamina propria extending focally into the muscularis propria in association with Rokitansky Aschoff sinuses. There is also patchy moderate fibrosis of the muscularis propria. The features are of chronic cholecystitis. No evidence of tumour is seen.

DIAGNOSIS:

  • Right nephrectomy: Papillary renal cell carcinoma Type 1 (Fuhrman Grade 2; Stage T2 NX MX); all surgical margins clear of tumour.
  • Gallbladder: Cholelithiasis; chronic cholecystitis.
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Case Information

rID: 49877
Case created: 7th Dec 2016
Last edited: 14th Apr 2017
System: Urogenital
Tag: rmh
Inclusion in quiz mode: Included

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