How To Diagnose Renal Cell Carcinoma

Transcription

1 History year-2-month-old male Date of admission:2008/05/07 ~ 2008/05/17, 共 11 天 Chief complaint: Left abdominal mass was noted for one month. Present illness: 1. Left abdominal mass was noted on 2008/04/09 due to healthy examination at Wan-Fang Hospital. 2. Then followed CT showed the mass at left kidney, upper pole. (Size: 7.5cm in diameter with smooth margin.) 3. No any GI/GU symptoms, including hematuria, frequency, urgency, dysuria, abdominal tenderness, diarrhea etc. 4. No body weight loss and no lose of appetite.

2 History - 2 Travel history: no travel since stroke Personal history: Food and drug allergy: (-); Drug abuse: (-) Smoking: (+) 1 ppd for 40 years; alcohol use: (-) Systematic disease (DM, HTN,.): (-) Family history: no special family disease Past history: 1. Left eye stroke this Jan. and under medical control at 新 光 hospital. 2. Bilateral hearing loss for 15 years and hearing aid was used. 3. Gout for 20 years but is not under medical control now. 4. RA for 15 years but is not under medical control now.

3 Physical examination Eye: impairment of vision, visual field defect (+) Musculoskeletal system: joint pain, joint stiffness Abdomen: tenderness, rebounding pain, muscle guarding (-) shifting dullness (-), Murphy sign (-), palpable mass: the biggest one at LLQ area. knocking pain (-) Other: no specific finding.

4 Lab data (2008/05/07) 急 診 生 化 Glucose 94 mg/dl BUN 13.1 mg/dl Creatinine 0.8 mg/dl GOT 13 IU/L GPT 16 IU/L Na 138 meq/l K 4.2 meq/l 尿 液 PH 7.0 protein (-), sugar (-), ketone (-), bilirubin (-) 血 液 WBC 6.60* 10^3 /ul RBC 4.44*10^6/ul HGB 13.7 g/dl HCT 40.1 % PLT 231*10^3/ ul Neut. 68.3% Lym. 22.7% Occult blood (-) RBC (-), WBC (-)

5 Chest X-ray (2008/05/07) Well expansion of lung without thoracic cage deformity. Some fibrocalcified lesions at left upper lung field. (old pulmonary tuberculosis?) Cardiomegaly, tortuous and calcified aortic knob. Normal appearance of bil. costo-phrenic angles.

6 KUB (2008/05/07) Enlargement of renal shadow on left side, ( soft tissue density over lateral aspect of left renal region.) Non-specific bowel gas pattern. Bil. clear psoas shadows. Stool impaction in the colon.

7 MRI (2008/05/08) AxT1 image: well-defined, homogeneous; isointense to hypointense relative to the renal cortex. AxT2 image: typically isointense to slightly hypointense. mildly hyperintense central scar. *tumor size: 6.5x6.4x7.3cm

8 MRI (2008/05/08)

9 Chest X-ray (2008/05/12) Left infra-hilar shadow is prominent. (Engorged vascular hilar shadow?) Enlarged heart and tortous aorta arch with calcification..

10 D/Dx (Renal tumor) Unilateral Renal mass 1.Benign Usually < 1cm in diameter angiomyolipoma, lipoma, fibroma. Usually > 5cm in diameter Renal oncocytoma. usually the identification of fat within the lesion indicate that it is benign. 2. Malignant Renal cell carcinoma(85%), urothelial carcinoma(5~10%), metastasis.

11 D/Dx (image finding) Renal oncocytoma Renal cell carcinoma Urothelial carcinoma (Transitional cell carcinoma)

12 Renal oncocytoma A well-defined fibrous capsule, with tumor tissue rarely penetrating the renal capsule, pelvis, collecting system, or perinephric fat. Accounts for approximately 3-7% of all renal neoplasms. The presence of a central scar on CT scans or MRIs and a spoke-wheel pattern of vessels on angiograms are often suggestive of oncocytoma. *The diagnosis of oncocytoma is predominantly pathologic.

13 Renal cell carcinoma Classic triad: flank pain, abdominal mass and hematuria.(10%) Fever (15%), weight loss (33%) Risk factors: smoking, obesity, Asbestos etc. Solid or calcified cyst should be suspected of RCC. Plain MRI: often difficult, because frequently the same signal intensity. there are very few cases visible on MRI not been detected by CT or US. CT: solid and highly enhancing mass. Central necrosis.

14 CT Renal cell carcinoma with central necrosis. There is tumor extension into the right renal vein as highlighted with an arrow. Contrast-enhanced MRI image

15 Urothelial carcinoma Accounts for 85-90% of all uroepithelial tumors. Most are solid with no characteristic gross findings. Exophytic, polypoid papillary growth pattern most common IVP: Filling defects in the upper urinary tract. CT: obstruction and dilatation of the ureter and pelvis proximal to the lesion; ureteral wall thickening.

16 Retrograde pyelogram hydronephrosis (yellow arrow) Filling defect at head of contrast column in ureter (red arrow) goblet" shaped dilatation distal to filling defect Non-contrast CT : Bilateral hydroureteronephrosis

17 Final diagnosis (pathology) Tissue source: kidney, left. (specimen: 2008/05/10) Abstract: 1. Grossly, there is a protruding tumor measuring 8.2 x 7.0 x 4.0 cm. in size located at the middle pole of the kidney. The tumor was well-defined, mahogany brown with central fibrous scar. 2. Microscopically, it shows a picture of oncocytoma of the kidney with a tumor composed entirely of cells with abundant acidophilic granular cytoplasm, growing in a nesting or focal tubular fashion. The nuclei are small, round and regular. 3. No papillary formation, clear cells or necrosis is present within the tumor. 4. Immunohistochemically, the tumor is positive for E-cadherin, and negative for CK7 and vimentin.

18 Renal oncocytoma Introduction Uncommon and consist of a pure population of oncocytes. (large well-differentiated neoplastic cells with intensely eosinophilic granular cytoplasm). Originate from the intercalated cells of the renal collecting duct. Accounts for approximately 3-7% of all renal neoplasms. About 2-12% of oncocytomas are multifocal, and 4-14% are bilateral. More common in males than females, with a rate of 2-3:1. The mean patient age is 60+ years.

19 Renal oncocytoma Pathology On cut sections, oncocytomas appear homogeneous, with a mahogany color; in contrast to yellow renal cell carcinomas (RCC). A fleshy central scar is a characteristic finding. However, necrosis, hemorrhage, and calcification, are rare findings.

20 Renal oncocytoma The main differential diagnosis on histologic analysis is chromophobe RCC, which also shows granular eosinophilic cytoplasm. However, RCC have perinuclear clearing. Immunohistochemical tests are also useful to differentiate oncocytoma from chromophobe RCC. (Chromophobe RCC demonstrates vimentin positivity, whereas oncocytoma shows cathepsin H positivity.) Renal oncocytomas almost invariably behave in a benign fashion. Even when very large, they are generally well encapsulated and are rarely invasive or associated with metastases. In less than 10% of cases, oncocytoma and chromophobe RCC may coexist.

21 Chromophobe RCC

22 Renal oncocytoma Symptom 17-21% of affected patients present with symptoms. Such as hematuria, flank pain, and palpable abdominal mass. In patients who present with symptoms, hematuria is more common than mass-like findings. **Approximately 56-91% are incidentally detected on imaging studies that have been performed for another indication.

23 Renal oncocytoma Image The imaging characteristics of oncocytomas and RCCs overlap, and differentiating an oncocytoma from an RCC and other solid renal neoplasms is not always possible with ultrasonography, CT scanning, or magnetic resonance imaging (MRI). The presence of a central scar on CT scans or MRIs and a spokewheel pattern of vessels on angiograms are often suggestive of oncocytoma but are not entirely specific.

24 Renal oncocytoma CT scan Non-enhanced: isoattenuating or slightly hyperattenuating relative to the kidney parenchyma. Contrast-enhanced: less attenuating than the renal parenchyma. A central hypoattenuating scar may be observed in 33% of cases. (cannot be differentiated from the central necrosis commonly found in RCC.) Calcification, necrosis, and hemorrhage are rare. Features of a malignant tumor are absent. ( invasion or infiltration into the perinephric fat, collecting system, or vessels.)

25 上 圖 Contrast-enhanced CT A well-defined, enhancing mass lesion in the lower pole of the left kidney. A central hypoattenuating stellate scar is seen. 上 圖 Contrast-enhanced CT A well-defined, exophytic, solid mass from the midpole of the left kidney. An atypical appearance of an oncocytoma, is less attenuating than the renal parenchyma, and does not show a scar.

26 Contrast enhanced CT The enhancement has a stellate or radiating "spoke wheel" appearance with a central scar. It has a well circumscribed border with normal appearing kidney inferolaterally. No calcifications are identified.

27 Renal oncocytoma MRI Non-enhanced T1-weighted: well-defined, homogeneous; isointense to hypointense relative to the renal cortex. T2-weighted: typically isointense to slightly hypointense; however, slight T2 hyperintensity has also been reported. IV gadopentetate dimeglumine contrast material: homogeneous enhancement, with a non-enhancing central scar. Features of a malignant tumor are absent. ( invasion or infiltration into the perinephric fat, collecting system, or vessels.)

28 T1-weighted MRI A homogeneous, hypointense, well-defined mass in the lower pole of the kidney.

29 T2-weighted MRI The lesion is hypointense and has a mildly hyperintense central scar.

30 Contrast-enhanced T1-weighted MRI Homogeneous enhancement of the mass with a nonenhancing central scar. The lack of any tumoral invasion into the perinephric fat.

31 Renal oncocytoma Ultrasound well-defined, homogeneous, and hypoechoic to isoechoic masses. The central scar cannot be confidently identified. Color Doppler ultrasonography may show central radiating vessels. Features of a malignant tumor are absent. ( invasion or infiltration into the perinephric fat, collecting system, or vessels.)

32 Renal oncocytoma Angiography Routine angiography is not performed to diagnose renal masses. A spoke-wheel arrangement of tumoral vessels, homogeneous tumoral contrast during the capillary phase. Sharp demarcation from the kidney and surrounding areas, and a peritumoral halo (lucent-rim sign). Bizarre neoplastic vessels are conspicuously absent. (in contrast to RCC)

33 Renal oncocytoma Intervention Percutaneous renal biopsy, fine-needle aspiration cytology, and frozen-section biopsy differentiation of oncocytoma from RCC. Treat a solid renal mass partial or total nephrectomy. Because of ~ 1. Statistically, RCC is the most common solid renal mass. 2. Infrequently, benign tumors such as oncocytoma are encountered. 3. Because of the overlap in imaging features and histologic appearances between oncocytomas and RCCs, accurate differentiation on preoperative imaging or percutaneous biopsy remains difficult. 4. The diagnosis is often retrospectively established by means of gross pathology and microscopy with special stains.

34 Renal oncocytoma Prognosis Oncocytomas are benign tumors, and the prognosis after total or partial nephrectomy is excellent. Recurrence at the resection site has not been reported. A few cases of local invasion and metastases have been reported in the literature, but these probably represent chromophobe RCC, rather than oncocytomas.