Imaging features of Impression choledocholithiasis, cholelithiasis, 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 tumor. Only approximately 1/3 of the tumor 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 tumor surface, to reveal a glistening intact capsule separating from the tumor. The tumor is located at least 20mm from the inked fat margin laterally, and at least 5mm from the inked fat margin posteriorly. The tumor 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 tumor. 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 tumor. The tumor bulges into perinephric adipose tissue but is separated from this by a fibrous capsule of varying thickness. The tumor 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 tumor.

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 tumor is seen.

DIAGNOSIS:

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