renal cell carcinoma radiology, classification and staging ,

1. DR ASHISH KUMAR GUPTA
PG RADIODIAGNOSIS
SLIMS

2. Renal cell carcinomas
 Malignant tumours derived from the
renal epithelium.
 It is the most common malignant renal
tumour,
 with a variety of radiographic
appearances.

4. Epidemiology
 Patients are typically 50-70 years of age
at presentation ,
 male female ratio 2:1 .
 Renal cell carcinomas are thought to be
the 8th most common adult malignancy,
 representing 2% of all cancers,
 and account for 80-90% of primary
malignant adult renal neoplasms .

5. Epidemiology
• Majority of RCC occurs sporadically
• Tobacco smoking contributes to 24-30% of
RCC cases
 - Tobacco results in a 2-fold increased
risk
• Occupational exposure to cadmium,
asbestos, petroleum
• Obesity
• Chronic phenacetin or aspirin use
• Acquired polycystic kidney disease due to
dialysis results in 30% increase risk

6. Epidemiology
 2-4% of RCC associated with inherited
disorder
 Von Hippel-Lindau disease
 Xp11.2 translocation
 familial clear cell cancer
 tuberous sclerosis

7. Clinical Presentation
Presentation is classically described as the
triad of:
 macroscopic haematuria: 60%
 flank pain: 40%
 palpable flank mass: 30-40%
 Symptoms secondary to metastatic
disease: dysnea & cough, seizure &
headache, bone pain

8. Clinical Presentation
Paraneoplastic syndrome
1. Polycythemia
2. Hypercalcemia
3. Hypertension
4. Hepatic dysfunction
5. Feminization
6. Masculinization
7. Cushing syndrome
8. Eosinophilia
9. Leukemoid reaction
10. Amyloidosis

9. Other Signs And Symptoms
 Weight loss (33%)
 Fever (20%)
 Night sweats
 Malaise
 Varicocele,
 usually left sided, due to obstruction of
the testicular vein (2% of males)

10. Metastasis
 The tendency of metastasize widely
before giving rise to any local symptoms
and signs.
 25% of RCC had metastasis
Most common location：
1. lung（more than 50%）
2. bone（33%）
3. Regional lymph nodes
4. Liver, adrenal, and brain

11. Classification of RCC
 CLEAR CELL RENAL CARCINOMA (conventional): 70-80%
 large uniform cells with clear
 highly vascular
 CLEAR CELL MULTILOCULAR RENAL CELL CARCINOMA
 PAPILLARY RENAL CELL CARCINOMA: 13-20%
 type I: sporadic, generally good prognosis
 type II: inherited, bilateral and multi focal
 CHROMOPHOBE RENAL CELL CARCINOMA: 5%
 similar histologically to renal oncocytomas
 best prognosis
 COLLECTING DUCT RENAL CELL CARCINOMA (Bellini duct):
<1%
 often younger patients
 worst prognosis
 RENAL MEDULLARY CARCINOMA: rare
 seen primarily in patients with sickle cell disease or sickle cell trait

12. 1. Clear cell renal cell
carcinoma CCRCC is a renal cortical tumor typically
characterized by malignant epithelial cells with
clear cytoplasm
 Clear cell RCC recapitulates(repeat during
growth) the epithelium of the proximal
convoluted tubules .
 The intra-cyto-plasmic glycogen and lipids get
dissolved during histologic processing,
rendering the cells “clear”
 A variable proportion of cells with granular
eosinophilic cytoplasm may be present

13. Imaging studies
 Imaging studies of CCRCC have shown
that extensive cystic degeneration with
associated necrosis ,
 Focal cystic necrosis is relatively
common.
 Focal calcification can be seen in 11-
26% of CCRCCs,
 Ossification may also be present

14. CLEAR CELL RENAL
CARCINOMA
• Contrast-enhanced CT scan
of a clear cell RCC shows an
expansile , heterogeneously
enhancing right renal mass
(arrows) with associated
hypervascular retroperitoneal
lymphadenopathy
•Contrast-enhanced CT scan
obtained during the cortico-
medullary phase shows a
predominantly cystic clear cell
RCC (arrows) with peripheral
solid, enhancing components

15. Clear Cell RCC
•Axial gadolinium-
enhanced T1-
weighted MR
image obtained
during the
corticomedullary
phase shows a
small,
homogeneously
enhancing,
hypervascular
clear cell RCC

16. 2. Multilocular Cystic RCC
 multiseptated cystic RCC whose septa contain
small clusters of clear cells.
 Multilocular cystic RCC is found in adults aged
20–76 years with a mean age of 51 years.
 Males predominate with a male-to-female ratio
of 3:1.
 characterized by septated, variable-sized cysts
separated from the kidney by a fibrous capsule
. The cyst fluid may be serous or hemorrhagic
 Asymmetric septal thickening may be seen.
Twenty percent of tumors show septal or wall
calcification

17. Multilocular Cystic RCC
Contrast-
enhanced
CT scan of
a
multilocular
cystic RCC
shows a
large,
expansile
cystic
mass

18. 3. Papillary RCC
 second most common histologic subtype,
making up 10%–15% of RCCs.
 Tumor epithelium is reminiscent of the
epithelium of the proximal convoluted
tubules
 papillary RCCs often contain areas of
hemorrhage, necrosis, and cystic
degeneration
 characterized by a predominantly papillary
growth pattern

19. imaging studies
 appear hypovascular and homogeneous
on imaging studies
 shows lesser degrees of contrast
enhancement than clear cell RCC at
contrast-enhanced CT
 important feature of papillary RCC is
that bilateral and multifocal tumors
 Larger tumors show heterogeneity due
to necrosis, hemorrhage, and
calcification

20. Papillary RCC
• Contrast-enhanced CT scan of a
papillary RCC shows a small
hypovascular mass (arrow) with
discrete foci of calcification
•Non-enhanced CT scan of a
papillary RCC shows a
complex cystic mass with
hemorrhage (arrow) and
associated retroperitoneal
lymph-adenopathy

21. MRI
 Axial T2-
weighted MR
image of a
papillary RCC
shows a round,
uniformly
hypointense
tumor (arrows).
Note the
multiple
bilateral renal
cysts
(arrowheads).

22. 4. Chromophobe RCC
 Chromophobe RCC is postulated to
differentiate toward type B intercalated
cells of the cortical collecting duct .
 Chromophobe RCC shows a mean age
of incidence in the 6th decade.
 Men and women are equally affected.
 Macroscopically, chromophobe RCCs
are well circumscribed, solid, tan-brown
tumors with a mildly lobulated surface

23. Image Studies
 Chromophobe RCC appears uniformly
hyperechoic at ultrasonography .
 Despite their large size, chromophobe
RCCs demonstrate relatively
homogeneous enhancement at CT and MR
imaging
 Chromophobe RCC may appear
hypointense on T2-weighted MR images.
At catheter angiography, chromophobe
RCC is commonly hypovascular

24. Chromophobe RCC
Axial gadolinium-
enhanced fat-saturated
three-dimensional
gradient-echo MR
image of a
chromophobe RCC
shows a relatively
hypovascular, expansile
right renal mass with
slightly heterogeneous
enhancement (arrows)

25. 5. Collecting Duct
Carcinoma
 highly aggressive subtype of RCC that accounts for
<1% of all malignant renal neoplasms.
 Origin from the medullary collecting duct is
suggested by immuno-cytochemistry findings that
are similar to principal cells of the collecting ducts of
Bellini .
 Collecting duct carcinoma shows a male-to-female
ratio of approximately 2:1.
 The age range is 13–83 years (mean age, 55 years).
 typically appears as a gray-white infiltrative
neoplasm with its epicenter in the pelvicaliceal
system
 characterized by an infiltrative growth pattern at
imaging


26. Image Studies
 Collecting duct carcinoma may be
hyperechoic, isoechoic, or hypoechoic to
renal parenchyma at sonography.
 At CT and MR imaging, collecting duct
carcinoma appears heterogeneous with
areas of necrosis, hemorrhage, and
calcification.
 Collecting duct carcinoma commonly
shows low signal intensity on T2-weighted
MR images and hypovascularity at catheter
angiography

27. Collecting Duct Carcinoma
Power Doppler
sonogram of a
collecting duct
carcinoma shows a
solid, hypovascular
medullary neoplasm
(arrows).

28. CECT
Contrast-enhanced
CT scan of a
collecting duct
carcinoma shows a
heterogeneously
enhancing left renal
mass (arrows) with
prominent
calcifications
(arrowheads).

29. 6. Renal Medullary
Carcinoma
 referred to as the seventh sickle cell nephropathy, is an
extremely rare malignant neoplasm occurring almost
exclusively in patients with sickle cell trait
 Renal medullary carcinoma is almost always found in
young patients; the typical age range is between 10 and
40 years (mean age, 22 years). The male-to-female ratio
is 2:1.
 appears as an infiltrative, heterogeneous mass with a
medullary epicenter
 Manifests as an infiltrative, heterogeneous medullary
neoplasm
 Hemorrhage and necrosis contribute to tumor
heterogeneity.
 Renal medullary carcinoma is typically associated with
caliectasis.

30. Image studies
 Renal medullary carcinoma appears
hypointense on T2-weighted MR images
likely due to the presence of by-products
of hemorrhage and necrosis.
 Tumors are typically hypovascular at
catheter angiography

31. Medullary Carcinoma
Contrast-enhanced
CT scan of a renal
medullary
carcinoma shows a
heterogeneously
enhancing right
renal mass (black
arrow) with
associated cystic
retroperitoneal
lymphadenopathy
(white arrows).

32. Imaging of RCC
 Ultrasonography
 Intravenous Urography (IVU):
 CT scanning: more sensitive, mass+renal
hilum, perinephric space and vena cava,
adrenals, regional LN and adjacent organs
 Renal Angiography
 MRI: to evaluate collecting system and IVC
involvement

33. ULTRASONOGRAPHY

34. USG
 Hyper echoic mostly in small tumors <3
cm
 Isoechoic / hypoechoic mostly in larger
tumors
 Cystic lesion with increase in acoustic
transmission due to extensive necrosis
 Inhomogeneity due to hemorrhage ,
necrosis , cystic degeneration

35. IVU of Right RCC

36. IVU
 Diminished function (parenchymal
replacement, hydronephrosis)
 Absence of contrast excretion (renal vein
occlusion)
 Necrotic part of tumour filled with
contrast media

37. NCCT
 Unenhanced
CT scan shows
a 2.5-cm-
diameter soft-
tissue mass
deforming the
contour of the
right kidney
(arrow)

38. corticomedullary phase
 Contrast-enhanced CT
scan obtained during
the corticomedullary
phase shows that the
mass is
hypoattenuating
compared with the
renal cortex and has
peripheral
enhancement (arrow).
The cortex is brightly
enhanced, whereas
the medulla is
relatively unenhanced.

39. nephrographic phase
 Contrast-
enhanced CT scan
obtained during the
nephrographic
phase shows the
hypervascular
mass is well
demarcated from
the homogeneously
enhancing renal
parenchyma
(arrow)

40. CT Scan of Left RCC
Heterogenous mass due to hemorrhagic /necrosis

41. CT
 On non-contrast CT the lesions appear of soft tissue attenuation.
 Larger lesions frequently have areas of necrosis.
 Approximately 30% demonstrate some calcification .
 During the corticomedullary phase of enhancement, 25-70 seconds
after administration of contrast, renal cell carcinomas demonstrate
variable enhancement, usually less than the normal cortex.
 Small lesions may enhance a similar amount and be difficult to
detect.
 In general small lesions enhance homogeneously, whereas larger
lesions have irregular enhancement due to areas of necrosis.
 The clear cell sub type may show much stronger enhancement

42. Cystic RCC

43. RCC invading renal vein

44. CT scan with 3D reconstruction

45. Neovascularity in Renal
Angiography
associated with RCC

46. Magnetic resonance scan
A, Magnetic resonance scan
of kidneys without
administration of gadolinium
suggests anterior right renal
mass.
B, After intravenous
administration of gadolinium-
labeled diethylene-triamine-
penta-acetic acid, MRI shows
enhancement of this mass
indicative of malignancy

47. MRI
 T1: often heterogeneous due to
necrosis, haemorrhage and solid
components
 T2: appearances depend on histology
 clear cell RCC: hyperintense
 papillary RCC: hypointense
 T1 C+ (Gd): often shows prompt arterial
enhancement

48. Tumor Staging (Robson
System)

49. Tumor Staging (International
TNM Staging System)

50. Differential Diagnosis
• Benign renal tumors
-Angiomyolipoma
• Renal Pelvis Cancer