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  IN THIS Article
 ::  Introduction
 ::  Case report
 ::  Discussion
 ::  References

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Year : 1986  |  Volume : 32  |  Issue : 4  |  Page : 239-40

Multilocular, predominantly cystic, renal cell carcinoma : an unusual gross appearance (a case report).







How to cite this article:
Deshpande R B, Pandit A A, Vora I M, Ravi R R, Dalvi A N, Nair H T, Shenoy S G. Multilocular, predominantly cystic, renal cell carcinoma : an unusual gross appearance (a case report). J Postgrad Med 1986;32:239


How to cite this URL:
Deshpande R B, Pandit A A, Vora I M, Ravi R R, Dalvi A N, Nair H T, Shenoy S G. Multilocular, predominantly cystic, renal cell carcinoma : an unusual gross appearance (a case report). J Postgrad Med [serial online] 1986 [cited 2019 Aug 20];32:239. Available from: http://www.jpgmonline.com/text.asp?1986/32/4/239/5315




  ::   Introduction Top

The gross appearance of renal cell carcinoma is fairly characteristic. In general, the tumours are irregularly lobulated, firm, and varying in size from 5 to 15 cm. Cut surface is aptly described as `variegated', due to degeneration, necrosis and haemorrhage. Infrequently cyst formation occurs following necrosis. We report here an otherwise typical renal cell carcinoma with an unusual multicystic "goitrous" appearance.

  ::   Case report Top

A 65 year old male was admitted with pain and lump in the right lumbar region. Ultrasonagraph revealed an essentially solid mass with a few hypoechogenic areas in the lower pole of the right kidney. The left kidney was essentially normal. A selective renal angiogram showed the mass to be hypervascular with multiple irregular vessels, multiple aneurysms and early draining veins. The left kidney was normal. The tumour was selectively embolized. Postembolisation angiographs showed marked reduction in the vascularity of the mass with improvement in the nephrogram in the upper pole. Right-sided radical nephrectomy was done 18 hours after embolisation.
Pathology:
Right kidney with tumour measured 13 x 9 x 7 cm. The tumour was irregularly lobulated, firm and occupied whole of the lower half of the kidney. The tumour measured 9 x 7 x 7 cm. The cut surface appeared grossly multicystic. The cysts ranged in size from 2 mm to 2 cm, and contained mainly greenish gelatinous fluid. Some of the larger cysts were multiloculated, traversed by thin membranous septae. Thick white fibrous bands traversed the mass irregularly forming cyst walls. The cut surface closely resembled "goitrous thyroid" [Fig. 1]. In addition, a few greyish solid nodules measuring 0.5 to 1 cm were seen in between the cysts. A large solid tumour mass, like that seen in typical carcinomas, was noted at the periphery of the cystic mass, adjacent to the normal parenchyma [Fig. 1].
Microscopically, the tumour showed characteristic picture of clear cell renal carcinoma with large cystic areas. Some of the cysts showed thick fibrous walls, filled with haemorrhagic fluid. Many of the cysts showed fragments of tumour lining the wall. Many others appeared like cystically dilated acini. Most of the cystic spaces contained pink acellular fluid. Solid tumour tissue intervened between the cysts. Thick fibrous bands traversed the tumour irregularly. The solid portion of the mass seen grossly at the periphery, showed a typical picture of clear cell carcinoma with acinar, and solid alveolar pattern; cysts were absent in the area.
Tumour vessels adjacent to larger cysts showed perivascular hyalinisation. An occasional tumour vessel was blocked by intimal fibro-myxoid proliferation. An occasional tumour vessel also showed embolized gel foam. There was no recent infarction of the tumour. The kidney parenchyma, however, showed an area of recent infarction with an adjacent arteriole blocked by gel foam.

  ::   Discussion Top

Cystic degeneration in renal carcinomas occurs infrequently. An occasional tumour may appear predominantly cystic.[1] We are reporting here such a case with a multilocular cystic appearance on gross.
True cystic renal carcinomas occur rarely. Wright and Walker6 described 3 "avascular" renal tumours which, on exploration, were proved to be papillary cystadenocarcinoma sprouting from the fibrous wails of large cysts. More recently, Reznicek et al[4] have reported 13 more such cases. Renal cell carcinomas also occur rarely in polycystic renal disease.[2] Rarely carcinoma may arise in a multilocular renal cyst.[3], [5]
The case described here showed characteristic hypervascularity on angiography. No cysts could be identified even on retrospective examination of the angiographs. However, ultrasound had indicated a few hypoechogenic zones. We believe that the unusual gross appearance is due to degeneration and necrosis, and not the true pattern of the tumour. Pre-operative embolisation of renal carcinomas results in massive haemorrhage and necrosis of the tumour. In an occasional case the tumour necrosis may be almost complete, rendering the tissue diagnosis of carcinoma difficult or almost impossible. Since nephrectomy is undertaken within 24 hours of embolisation cyst formation is not seen. In the case reported here, nephrectomy was done 18 hours after embolisation. Hence it is unlikely that embolisation caused cystic degeneration.

  ::   References Top

1.Bennington, J. L. and Beckwith, J. B.: Tumours of the kidney, renal pelvis, and ureter. In, "Atlas of Tumour Pathology, Second series. Armed Forces Institute of Pathology. Washington D.C. 1975, p. 129.   Back to cited text no. 1    
2.Kumar, S., Cederbaum, A. I. and Pletka, P. G.: Renal cell carcinoma in polycystic kidneys: Case report and review of literature. J. Urol., 124: 708-709, 1980.  Back to cited text no. 2    
3.Lewis, R. H., Clark, M. A., Dobson, C. L. and O'Connel, K. J.: Multilocular cystic renal adenocarcinoma arising in solitary kidney. J. Urol., 127: 314-316 1982.  Back to cited text no. 3    
4.Reznicek, S. B., Narayana, A. S. and Culp, D. A.: Cystadenocarcinoma of kidney. A profile of 13 cases. J. Urol., 134: 256-259, 1985.  Back to cited text no. 4    
5.Taxy, J. B. and Marshall, F. F.: Multilobular renal cysts in adults. Possible relationship to renal adenocarcinoma. Arch. Pathol. and Lab. Med., 107: 633-637, 1983.  Back to cited text no. 5    
6.Wright, F. W. and Walker, M. M.: The radiological diagnosis of "avascular" renal tumours. Brit. J, Urol., 47: 253-258, 1975.  Back to cited text no. 6    

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Online since 12th February '04
2004 - Journal of Postgraduate Medicine
Official Publication of the Staff Society of the Seth GS Medical College and KEM Hospital, Mumbai, India
Published by Wolters Kluwer - Medknow