renal cell carcinoma radiology

renal cell carcinoma radiology, classification and staging ,

1. RENAL CELL CARCINOMA 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.

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

4. 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

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

6. 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

7. 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

8. 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)

9. 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

10. 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

11. 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

12. 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

13. 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 

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

15. 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

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

17. 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

18. 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

19. 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

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

21. 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

22. 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

23. 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 )

24. 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  

25. 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

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

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

28. 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 .

29. 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 

30. 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).

31. 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

32. ULTRASONOGRAPHY

33. 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

34. IVU of Right RCC

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

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

37. 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.

38. 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)

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

40. 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

41. Cystic RCC

42. RCC invading renal vein

43. CT scan with 3D reconstruction

44. Neovascularity in Renal Angiography associated with RCC

45. 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

46. 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

47. Tumor Staging (Robson System)

48. Tumor Staging (International TNM Staging System)

49. Differential Diagnosis Benign renal tumors - Angiomyolipoma Renal Pelvis Cancer