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DR ASHISH KUMAR GUPTA
PG RADIODIAGNOSIS
SLIMS
Renal cell carcinomas
Malignant tumours derived from the
renal epithelium
It is the most common malignant renal
tumour
with a variety of radiographic
appearances
Epidemiology
Patients are typically 50-70 years of age
at presentation
male female ratio 21
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
Epidemiology
bull Majority of RCC occurs sporadically
bull Tobacco smoking contributes to 24-30 of RCC cases
- Tobacco results in a 2-fold increased risk
bull Occupational exposure to cadmium asbestos petroleum
bull Obesity
bull Chronic phenacetin or aspirin use
bull Acquired polycystic kidney disease due to dialysis results in 30 increase risk
Epidemiology
2-4 of RCC associated with inherited
disorder
Von Hippel-Lindau disease
Xp112 translocation
familial clear cell cancer
tuberous sclerosis
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 amp cough seizure amp headache bone pain
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
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)
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
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) lt1 often younger patients
worst prognosis
RENAL MEDULLARY CARCINOMA rare seen primarily in patients with sickle cell disease or sickle cell trait
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 ldquoclearrdquo
A variable proportion of cells with granular eosinophilic cytoplasm may be present
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
CLEAR CELL RENAL
CARCINOMAbull Contrast-enhanced CT scan
of a clear cell RCC shows an
expansile heterogeneously
enhancing right renal mass
(arrows) with associated
hypervascular retroperitoneal
lymphadenopathy
bullContrast-enhanced CT scan
obtained during the cortico-
medullary phase shows a
predominantly cystic clear cell
RCC (arrows) with peripheral
solid enhancing components
Clear Cell RCC
bullAxial gadolinium-
enhanced T1-
weighted MR
image obtained
during the
corticomedullary
phase shows a
small
homogeneously
enhancing
hypervascular
clear cell RCC
2 Multilocular Cystic RCC
multiseptated cystic RCC whose septa contain small clusters of clear cells
Multilocular cystic RCC is found in adults aged 20ndash76 years with a mean age of 51 years
Males predominate with a male-to-female ratio of 31
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
Multilocular Cystic RCC
Contrast-
enhanced
CT scan of
a
multilocular
cystic RCC
shows a
large
expansile
cystic
mass
3 Papillary RCC
second most common histologic subtype making up 10ndash15 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
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
Papillary RCC
bull Contrast-enhanced CT scan of a
papillary RCC shows a small
hypovascular mass (arrow) with
discrete foci of calcification
bullNon-enhanced CT scan of a
papillary RCC shows a
complex cystic mass with
hemorrhage (arrow) and
associated retroperitoneal
lymph-adenopathy
MRI
Axial T2-weighted MR image of a papillary RCC shows a round uniformly hypointensetumor (arrows) Note the multiple bilateral renal cysts (arrowheads)
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
Image Studies
Chromophobe RCC appears uniformly hyperechoic at ultrasonography
Despite their large size chromophobeRCCs demonstrate relatively homogeneous enhancement at CT and MR imaging
Chromophobe RCC may appear hypointense on T2-weighted MR images At catheter angiography chromophobeRCC is commonly hypovascular
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)
5 Collecting Duct
Carcinoma highly aggressive subtype of RCC that accounts for
lt1 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 21
The age range is 13ndash83 years (mean age 55 years)
typically appears as a gray-white infiltrative neoplasm with its epicenter in the pelvicalicealsystem
characterized by an infiltrative growth pattern at imaging
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
Collecting Duct Carcinoma
Power Doppler
sonogram of a
collecting duct
carcinoma shows a
solid hypovascular
medullary neoplasm
(arrows)
CECT
Contrast-enhanced
CT scan of a
collecting duct
carcinoma shows a
heterogeneously
enhancing left renal
mass (arrows) with
prominent
calcifications
(arrowheads)
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 21
appears as an infiltrative heterogeneous mass with a medullary epicenter
Manifests as an infiltrative heterogeneous medullaryneoplasm
Hemorrhage and necrosis contribute to tumor heterogeneity
Renal medullary carcinoma is typically associated with caliectasis
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
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)
Imaging of RCC
Ultrasonography
Intravenous Urography (IVU)
CT scanning more sensitive mass+renalhilum perinephric space and vena cava adrenals regional LN and adjacent organs
Renal Angiography
MRI to evaluate collecting system and IVC involvement
ULTRASONOGRAPHY
USG
Hyper echoic mostly in small tumors lt3
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
IVU of Right RCC
IVU
Diminished function (parenchymal
replacement hydronephrosis)
Absence of contrast excretion (renal vein
occlusion)
Necrotic part of tumour filled with
contrast media
NCCT
Unenhanced
CT scan shows
a 25-cm-
diameter soft-
tissue mass
deforming the
contour of the
right kidney
(arrow)
corticomedullary phase
Contrast-enhanced CT scan obtained during the corticomedullaryphase shows that the mass is hypoattenuatingcompared with the renal cortex and has peripheral enhancement (arrow) The cortex is brightly enhanced whereas the medulla is relatively unenhanced
nephrographic phase
Contrast-enhanced CT scan obtained during the nephrographicphase shows the hypervascularmass is well demarcated from the homogeneously enhancing renal parenchyma (arrow)
CT Scan of Left RCC
Heterogenous mass due to hemorrhagic necrosis
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
Cystic RCC
RCC invading renal vein
CT scan with 3D reconstruction
Neovascularity in Renal
Angiography
associated with RCC
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
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
Tumor Staging (Robson
System)
Tumor Staging (International
TNM Staging System)
Differential Diagnosis
bull Benign renal tumors
-Angiomyolipoma
bull Renal Pelvis Cancer
Renal cell carcinomas
Malignant tumours derived from the
renal epithelium
It is the most common malignant renal
tumour
with a variety of radiographic
appearances
Epidemiology
Patients are typically 50-70 years of age
at presentation
male female ratio 21
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
Epidemiology
bull Majority of RCC occurs sporadically
bull Tobacco smoking contributes to 24-30 of RCC cases
- Tobacco results in a 2-fold increased risk
bull Occupational exposure to cadmium asbestos petroleum
bull Obesity
bull Chronic phenacetin or aspirin use
bull Acquired polycystic kidney disease due to dialysis results in 30 increase risk
Epidemiology
2-4 of RCC associated with inherited
disorder
Von Hippel-Lindau disease
Xp112 translocation
familial clear cell cancer
tuberous sclerosis
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 amp cough seizure amp headache bone pain
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
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)
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
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) lt1 often younger patients
worst prognosis
RENAL MEDULLARY CARCINOMA rare seen primarily in patients with sickle cell disease or sickle cell trait
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 ldquoclearrdquo
A variable proportion of cells with granular eosinophilic cytoplasm may be present
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
CLEAR CELL RENAL
CARCINOMAbull Contrast-enhanced CT scan
of a clear cell RCC shows an
expansile heterogeneously
enhancing right renal mass
(arrows) with associated
hypervascular retroperitoneal
lymphadenopathy
bullContrast-enhanced CT scan
obtained during the cortico-
medullary phase shows a
predominantly cystic clear cell
RCC (arrows) with peripheral
solid enhancing components
Clear Cell RCC
bullAxial gadolinium-
enhanced T1-
weighted MR
image obtained
during the
corticomedullary
phase shows a
small
homogeneously
enhancing
hypervascular
clear cell RCC
2 Multilocular Cystic RCC
multiseptated cystic RCC whose septa contain small clusters of clear cells
Multilocular cystic RCC is found in adults aged 20ndash76 years with a mean age of 51 years
Males predominate with a male-to-female ratio of 31
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
Multilocular Cystic RCC
Contrast-
enhanced
CT scan of
a
multilocular
cystic RCC
shows a
large
expansile
cystic
mass
3 Papillary RCC
second most common histologic subtype making up 10ndash15 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
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
Papillary RCC
bull Contrast-enhanced CT scan of a
papillary RCC shows a small
hypovascular mass (arrow) with
discrete foci of calcification
bullNon-enhanced CT scan of a
papillary RCC shows a
complex cystic mass with
hemorrhage (arrow) and
associated retroperitoneal
lymph-adenopathy
MRI
Axial T2-weighted MR image of a papillary RCC shows a round uniformly hypointensetumor (arrows) Note the multiple bilateral renal cysts (arrowheads)
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
Image Studies
Chromophobe RCC appears uniformly hyperechoic at ultrasonography
Despite their large size chromophobeRCCs demonstrate relatively homogeneous enhancement at CT and MR imaging
Chromophobe RCC may appear hypointense on T2-weighted MR images At catheter angiography chromophobeRCC is commonly hypovascular
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)
5 Collecting Duct
Carcinoma highly aggressive subtype of RCC that accounts for
lt1 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 21
The age range is 13ndash83 years (mean age 55 years)
typically appears as a gray-white infiltrative neoplasm with its epicenter in the pelvicalicealsystem
characterized by an infiltrative growth pattern at imaging
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
Collecting Duct Carcinoma
Power Doppler
sonogram of a
collecting duct
carcinoma shows a
solid hypovascular
medullary neoplasm
(arrows)
CECT
Contrast-enhanced
CT scan of a
collecting duct
carcinoma shows a
heterogeneously
enhancing left renal
mass (arrows) with
prominent
calcifications
(arrowheads)
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 21
appears as an infiltrative heterogeneous mass with a medullary epicenter
Manifests as an infiltrative heterogeneous medullaryneoplasm
Hemorrhage and necrosis contribute to tumor heterogeneity
Renal medullary carcinoma is typically associated with caliectasis
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
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)
Imaging of RCC
Ultrasonography
Intravenous Urography (IVU)
CT scanning more sensitive mass+renalhilum perinephric space and vena cava adrenals regional LN and adjacent organs
Renal Angiography
MRI to evaluate collecting system and IVC involvement
ULTRASONOGRAPHY
USG
Hyper echoic mostly in small tumors lt3
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
IVU of Right RCC
IVU
Diminished function (parenchymal
replacement hydronephrosis)
Absence of contrast excretion (renal vein
occlusion)
Necrotic part of tumour filled with
contrast media
NCCT
Unenhanced
CT scan shows
a 25-cm-
diameter soft-
tissue mass
deforming the
contour of the
right kidney
(arrow)
corticomedullary phase
Contrast-enhanced CT scan obtained during the corticomedullaryphase shows that the mass is hypoattenuatingcompared with the renal cortex and has peripheral enhancement (arrow) The cortex is brightly enhanced whereas the medulla is relatively unenhanced
nephrographic phase
Contrast-enhanced CT scan obtained during the nephrographicphase shows the hypervascularmass is well demarcated from the homogeneously enhancing renal parenchyma (arrow)
CT Scan of Left RCC
Heterogenous mass due to hemorrhagic necrosis
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
Cystic RCC
RCC invading renal vein
CT scan with 3D reconstruction
Neovascularity in Renal
Angiography
associated with RCC
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
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
Tumor Staging (Robson
System)
Tumor Staging (International
TNM Staging System)
Differential Diagnosis
bull Benign renal tumors
-Angiomyolipoma
bull Renal Pelvis Cancer
Epidemiology
Patients are typically 50-70 years of age
at presentation
male female ratio 21
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
Epidemiology
bull Majority of RCC occurs sporadically
bull Tobacco smoking contributes to 24-30 of RCC cases
- Tobacco results in a 2-fold increased risk
bull Occupational exposure to cadmium asbestos petroleum
bull Obesity
bull Chronic phenacetin or aspirin use
bull Acquired polycystic kidney disease due to dialysis results in 30 increase risk
Epidemiology
2-4 of RCC associated with inherited
disorder
Von Hippel-Lindau disease
Xp112 translocation
familial clear cell cancer
tuberous sclerosis
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 amp cough seizure amp headache bone pain
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
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)
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
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) lt1 often younger patients
worst prognosis
RENAL MEDULLARY CARCINOMA rare seen primarily in patients with sickle cell disease or sickle cell trait
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 ldquoclearrdquo
A variable proportion of cells with granular eosinophilic cytoplasm may be present
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
CLEAR CELL RENAL
CARCINOMAbull Contrast-enhanced CT scan
of a clear cell RCC shows an
expansile heterogeneously
enhancing right renal mass
(arrows) with associated
hypervascular retroperitoneal
lymphadenopathy
bullContrast-enhanced CT scan
obtained during the cortico-
medullary phase shows a
predominantly cystic clear cell
RCC (arrows) with peripheral
solid enhancing components
Clear Cell RCC
bullAxial gadolinium-
enhanced T1-
weighted MR
image obtained
during the
corticomedullary
phase shows a
small
homogeneously
enhancing
hypervascular
clear cell RCC
2 Multilocular Cystic RCC
multiseptated cystic RCC whose septa contain small clusters of clear cells
Multilocular cystic RCC is found in adults aged 20ndash76 years with a mean age of 51 years
Males predominate with a male-to-female ratio of 31
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
Multilocular Cystic RCC
Contrast-
enhanced
CT scan of
a
multilocular
cystic RCC
shows a
large
expansile
cystic
mass
3 Papillary RCC
second most common histologic subtype making up 10ndash15 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
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
Papillary RCC
bull Contrast-enhanced CT scan of a
papillary RCC shows a small
hypovascular mass (arrow) with
discrete foci of calcification
bullNon-enhanced CT scan of a
papillary RCC shows a
complex cystic mass with
hemorrhage (arrow) and
associated retroperitoneal
lymph-adenopathy
MRI
Axial T2-weighted MR image of a papillary RCC shows a round uniformly hypointensetumor (arrows) Note the multiple bilateral renal cysts (arrowheads)
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
Image Studies
Chromophobe RCC appears uniformly hyperechoic at ultrasonography
Despite their large size chromophobeRCCs demonstrate relatively homogeneous enhancement at CT and MR imaging
Chromophobe RCC may appear hypointense on T2-weighted MR images At catheter angiography chromophobeRCC is commonly hypovascular
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)
5 Collecting Duct
Carcinoma highly aggressive subtype of RCC that accounts for
lt1 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 21
The age range is 13ndash83 years (mean age 55 years)
typically appears as a gray-white infiltrative neoplasm with its epicenter in the pelvicalicealsystem
characterized by an infiltrative growth pattern at imaging
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
Collecting Duct Carcinoma
Power Doppler
sonogram of a
collecting duct
carcinoma shows a
solid hypovascular
medullary neoplasm
(arrows)
CECT
Contrast-enhanced
CT scan of a
collecting duct
carcinoma shows a
heterogeneously
enhancing left renal
mass (arrows) with
prominent
calcifications
(arrowheads)
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 21
appears as an infiltrative heterogeneous mass with a medullary epicenter
Manifests as an infiltrative heterogeneous medullaryneoplasm
Hemorrhage and necrosis contribute to tumor heterogeneity
Renal medullary carcinoma is typically associated with caliectasis
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
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)
Imaging of RCC
Ultrasonography
Intravenous Urography (IVU)
CT scanning more sensitive mass+renalhilum perinephric space and vena cava adrenals regional LN and adjacent organs
Renal Angiography
MRI to evaluate collecting system and IVC involvement
ULTRASONOGRAPHY
USG
Hyper echoic mostly in small tumors lt3
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
IVU of Right RCC
IVU
Diminished function (parenchymal
replacement hydronephrosis)
Absence of contrast excretion (renal vein
occlusion)
Necrotic part of tumour filled with
contrast media
NCCT
Unenhanced
CT scan shows
a 25-cm-
diameter soft-
tissue mass
deforming the
contour of the
right kidney
(arrow)
corticomedullary phase
Contrast-enhanced CT scan obtained during the corticomedullaryphase shows that the mass is hypoattenuatingcompared with the renal cortex and has peripheral enhancement (arrow) The cortex is brightly enhanced whereas the medulla is relatively unenhanced
nephrographic phase
Contrast-enhanced CT scan obtained during the nephrographicphase shows the hypervascularmass is well demarcated from the homogeneously enhancing renal parenchyma (arrow)
CT Scan of Left RCC
Heterogenous mass due to hemorrhagic necrosis
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
Cystic RCC
RCC invading renal vein
CT scan with 3D reconstruction
Neovascularity in Renal
Angiography
associated with RCC
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
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
Tumor Staging (Robson
System)
Tumor Staging (International
TNM Staging System)
Differential Diagnosis
bull Benign renal tumors
-Angiomyolipoma
bull Renal Pelvis Cancer
Epidemiology
bull Majority of RCC occurs sporadically
bull Tobacco smoking contributes to 24-30 of RCC cases
- Tobacco results in a 2-fold increased risk
bull Occupational exposure to cadmium asbestos petroleum
bull Obesity
bull Chronic phenacetin or aspirin use
bull Acquired polycystic kidney disease due to dialysis results in 30 increase risk
Epidemiology
2-4 of RCC associated with inherited
disorder
Von Hippel-Lindau disease
Xp112 translocation
familial clear cell cancer
tuberous sclerosis
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 amp cough seizure amp headache bone pain
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
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)
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
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) lt1 often younger patients
worst prognosis
RENAL MEDULLARY CARCINOMA rare seen primarily in patients with sickle cell disease or sickle cell trait
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 ldquoclearrdquo
A variable proportion of cells with granular eosinophilic cytoplasm may be present
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
CLEAR CELL RENAL
CARCINOMAbull Contrast-enhanced CT scan
of a clear cell RCC shows an
expansile heterogeneously
enhancing right renal mass
(arrows) with associated
hypervascular retroperitoneal
lymphadenopathy
bullContrast-enhanced CT scan
obtained during the cortico-
medullary phase shows a
predominantly cystic clear cell
RCC (arrows) with peripheral
solid enhancing components
Clear Cell RCC
bullAxial gadolinium-
enhanced T1-
weighted MR
image obtained
during the
corticomedullary
phase shows a
small
homogeneously
enhancing
hypervascular
clear cell RCC
2 Multilocular Cystic RCC
multiseptated cystic RCC whose septa contain small clusters of clear cells
Multilocular cystic RCC is found in adults aged 20ndash76 years with a mean age of 51 years
Males predominate with a male-to-female ratio of 31
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
Multilocular Cystic RCC
Contrast-
enhanced
CT scan of
a
multilocular
cystic RCC
shows a
large
expansile
cystic
mass
3 Papillary RCC
second most common histologic subtype making up 10ndash15 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
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
Papillary RCC
bull Contrast-enhanced CT scan of a
papillary RCC shows a small
hypovascular mass (arrow) with
discrete foci of calcification
bullNon-enhanced CT scan of a
papillary RCC shows a
complex cystic mass with
hemorrhage (arrow) and
associated retroperitoneal
lymph-adenopathy
MRI
Axial T2-weighted MR image of a papillary RCC shows a round uniformly hypointensetumor (arrows) Note the multiple bilateral renal cysts (arrowheads)
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
Image Studies
Chromophobe RCC appears uniformly hyperechoic at ultrasonography
Despite their large size chromophobeRCCs demonstrate relatively homogeneous enhancement at CT and MR imaging
Chromophobe RCC may appear hypointense on T2-weighted MR images At catheter angiography chromophobeRCC is commonly hypovascular
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)
5 Collecting Duct
Carcinoma highly aggressive subtype of RCC that accounts for
lt1 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 21
The age range is 13ndash83 years (mean age 55 years)
typically appears as a gray-white infiltrative neoplasm with its epicenter in the pelvicalicealsystem
characterized by an infiltrative growth pattern at imaging
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
Collecting Duct Carcinoma
Power Doppler
sonogram of a
collecting duct
carcinoma shows a
solid hypovascular
medullary neoplasm
(arrows)
CECT
Contrast-enhanced
CT scan of a
collecting duct
carcinoma shows a
heterogeneously
enhancing left renal
mass (arrows) with
prominent
calcifications
(arrowheads)
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 21
appears as an infiltrative heterogeneous mass with a medullary epicenter
Manifests as an infiltrative heterogeneous medullaryneoplasm
Hemorrhage and necrosis contribute to tumor heterogeneity
Renal medullary carcinoma is typically associated with caliectasis
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
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)
Imaging of RCC
Ultrasonography
Intravenous Urography (IVU)
CT scanning more sensitive mass+renalhilum perinephric space and vena cava adrenals regional LN and adjacent organs
Renal Angiography
MRI to evaluate collecting system and IVC involvement
ULTRASONOGRAPHY
USG
Hyper echoic mostly in small tumors lt3
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
IVU of Right RCC
IVU
Diminished function (parenchymal
replacement hydronephrosis)
Absence of contrast excretion (renal vein
occlusion)
Necrotic part of tumour filled with
contrast media
NCCT
Unenhanced
CT scan shows
a 25-cm-
diameter soft-
tissue mass
deforming the
contour of the
right kidney
(arrow)
corticomedullary phase
Contrast-enhanced CT scan obtained during the corticomedullaryphase shows that the mass is hypoattenuatingcompared with the renal cortex and has peripheral enhancement (arrow) The cortex is brightly enhanced whereas the medulla is relatively unenhanced
nephrographic phase
Contrast-enhanced CT scan obtained during the nephrographicphase shows the hypervascularmass is well demarcated from the homogeneously enhancing renal parenchyma (arrow)
CT Scan of Left RCC
Heterogenous mass due to hemorrhagic necrosis
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
Cystic RCC
RCC invading renal vein
CT scan with 3D reconstruction
Neovascularity in Renal
Angiography
associated with RCC
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
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
Tumor Staging (Robson
System)
Tumor Staging (International
TNM Staging System)
Differential Diagnosis
bull Benign renal tumors
-Angiomyolipoma
bull Renal Pelvis Cancer
Epidemiology
2-4 of RCC associated with inherited
disorder
Von Hippel-Lindau disease
Xp112 translocation
familial clear cell cancer
tuberous sclerosis
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 amp cough seizure amp headache bone pain
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
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)
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
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) lt1 often younger patients
worst prognosis
RENAL MEDULLARY CARCINOMA rare seen primarily in patients with sickle cell disease or sickle cell trait
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 ldquoclearrdquo
A variable proportion of cells with granular eosinophilic cytoplasm may be present
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
CLEAR CELL RENAL
CARCINOMAbull Contrast-enhanced CT scan
of a clear cell RCC shows an
expansile heterogeneously
enhancing right renal mass
(arrows) with associated
hypervascular retroperitoneal
lymphadenopathy
bullContrast-enhanced CT scan
obtained during the cortico-
medullary phase shows a
predominantly cystic clear cell
RCC (arrows) with peripheral
solid enhancing components
Clear Cell RCC
bullAxial gadolinium-
enhanced T1-
weighted MR
image obtained
during the
corticomedullary
phase shows a
small
homogeneously
enhancing
hypervascular
clear cell RCC
2 Multilocular Cystic RCC
multiseptated cystic RCC whose septa contain small clusters of clear cells
Multilocular cystic RCC is found in adults aged 20ndash76 years with a mean age of 51 years
Males predominate with a male-to-female ratio of 31
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
Multilocular Cystic RCC
Contrast-
enhanced
CT scan of
a
multilocular
cystic RCC
shows a
large
expansile
cystic
mass
3 Papillary RCC
second most common histologic subtype making up 10ndash15 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
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
Papillary RCC
bull Contrast-enhanced CT scan of a
papillary RCC shows a small
hypovascular mass (arrow) with
discrete foci of calcification
bullNon-enhanced CT scan of a
papillary RCC shows a
complex cystic mass with
hemorrhage (arrow) and
associated retroperitoneal
lymph-adenopathy
MRI
Axial T2-weighted MR image of a papillary RCC shows a round uniformly hypointensetumor (arrows) Note the multiple bilateral renal cysts (arrowheads)
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
Image Studies
Chromophobe RCC appears uniformly hyperechoic at ultrasonography
Despite their large size chromophobeRCCs demonstrate relatively homogeneous enhancement at CT and MR imaging
Chromophobe RCC may appear hypointense on T2-weighted MR images At catheter angiography chromophobeRCC is commonly hypovascular
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)
5 Collecting Duct
Carcinoma highly aggressive subtype of RCC that accounts for
lt1 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 21
The age range is 13ndash83 years (mean age 55 years)
typically appears as a gray-white infiltrative neoplasm with its epicenter in the pelvicalicealsystem
characterized by an infiltrative growth pattern at imaging
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
Collecting Duct Carcinoma
Power Doppler
sonogram of a
collecting duct
carcinoma shows a
solid hypovascular
medullary neoplasm
(arrows)
CECT
Contrast-enhanced
CT scan of a
collecting duct
carcinoma shows a
heterogeneously
enhancing left renal
mass (arrows) with
prominent
calcifications
(arrowheads)
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 21
appears as an infiltrative heterogeneous mass with a medullary epicenter
Manifests as an infiltrative heterogeneous medullaryneoplasm
Hemorrhage and necrosis contribute to tumor heterogeneity
Renal medullary carcinoma is typically associated with caliectasis
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
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)
Imaging of RCC
Ultrasonography
Intravenous Urography (IVU)
CT scanning more sensitive mass+renalhilum perinephric space and vena cava adrenals regional LN and adjacent organs
Renal Angiography
MRI to evaluate collecting system and IVC involvement
ULTRASONOGRAPHY
USG
Hyper echoic mostly in small tumors lt3
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
IVU of Right RCC
IVU
Diminished function (parenchymal
replacement hydronephrosis)
Absence of contrast excretion (renal vein
occlusion)
Necrotic part of tumour filled with
contrast media
NCCT
Unenhanced
CT scan shows
a 25-cm-
diameter soft-
tissue mass
deforming the
contour of the
right kidney
(arrow)
corticomedullary phase
Contrast-enhanced CT scan obtained during the corticomedullaryphase shows that the mass is hypoattenuatingcompared with the renal cortex and has peripheral enhancement (arrow) The cortex is brightly enhanced whereas the medulla is relatively unenhanced
nephrographic phase
Contrast-enhanced CT scan obtained during the nephrographicphase shows the hypervascularmass is well demarcated from the homogeneously enhancing renal parenchyma (arrow)
CT Scan of Left RCC
Heterogenous mass due to hemorrhagic necrosis
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
Cystic RCC
RCC invading renal vein
CT scan with 3D reconstruction
Neovascularity in Renal
Angiography
associated with RCC
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
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
Tumor Staging (Robson
System)
Tumor Staging (International
TNM Staging System)
Differential Diagnosis
bull Benign renal tumors
-Angiomyolipoma
bull Renal Pelvis Cancer
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 amp cough seizure amp headache bone pain
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
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)
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
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) lt1 often younger patients
worst prognosis
RENAL MEDULLARY CARCINOMA rare seen primarily in patients with sickle cell disease or sickle cell trait
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 ldquoclearrdquo
A variable proportion of cells with granular eosinophilic cytoplasm may be present
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
CLEAR CELL RENAL
CARCINOMAbull Contrast-enhanced CT scan
of a clear cell RCC shows an
expansile heterogeneously
enhancing right renal mass
(arrows) with associated
hypervascular retroperitoneal
lymphadenopathy
bullContrast-enhanced CT scan
obtained during the cortico-
medullary phase shows a
predominantly cystic clear cell
RCC (arrows) with peripheral
solid enhancing components
Clear Cell RCC
bullAxial gadolinium-
enhanced T1-
weighted MR
image obtained
during the
corticomedullary
phase shows a
small
homogeneously
enhancing
hypervascular
clear cell RCC
2 Multilocular Cystic RCC
multiseptated cystic RCC whose septa contain small clusters of clear cells
Multilocular cystic RCC is found in adults aged 20ndash76 years with a mean age of 51 years
Males predominate with a male-to-female ratio of 31
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
Multilocular Cystic RCC
Contrast-
enhanced
CT scan of
a
multilocular
cystic RCC
shows a
large
expansile
cystic
mass
3 Papillary RCC
second most common histologic subtype making up 10ndash15 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
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
Papillary RCC
bull Contrast-enhanced CT scan of a
papillary RCC shows a small
hypovascular mass (arrow) with
discrete foci of calcification
bullNon-enhanced CT scan of a
papillary RCC shows a
complex cystic mass with
hemorrhage (arrow) and
associated retroperitoneal
lymph-adenopathy
MRI
Axial T2-weighted MR image of a papillary RCC shows a round uniformly hypointensetumor (arrows) Note the multiple bilateral renal cysts (arrowheads)
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
Image Studies
Chromophobe RCC appears uniformly hyperechoic at ultrasonography
Despite their large size chromophobeRCCs demonstrate relatively homogeneous enhancement at CT and MR imaging
Chromophobe RCC may appear hypointense on T2-weighted MR images At catheter angiography chromophobeRCC is commonly hypovascular
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)
5 Collecting Duct
Carcinoma highly aggressive subtype of RCC that accounts for
lt1 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 21
The age range is 13ndash83 years (mean age 55 years)
typically appears as a gray-white infiltrative neoplasm with its epicenter in the pelvicalicealsystem
characterized by an infiltrative growth pattern at imaging
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
Collecting Duct Carcinoma
Power Doppler
sonogram of a
collecting duct
carcinoma shows a
solid hypovascular
medullary neoplasm
(arrows)
CECT
Contrast-enhanced
CT scan of a
collecting duct
carcinoma shows a
heterogeneously
enhancing left renal
mass (arrows) with
prominent
calcifications
(arrowheads)
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 21
appears as an infiltrative heterogeneous mass with a medullary epicenter
Manifests as an infiltrative heterogeneous medullaryneoplasm
Hemorrhage and necrosis contribute to tumor heterogeneity
Renal medullary carcinoma is typically associated with caliectasis
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
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)
Imaging of RCC
Ultrasonography
Intravenous Urography (IVU)
CT scanning more sensitive mass+renalhilum perinephric space and vena cava adrenals regional LN and adjacent organs
Renal Angiography
MRI to evaluate collecting system and IVC involvement
ULTRASONOGRAPHY
USG
Hyper echoic mostly in small tumors lt3
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
IVU of Right RCC
IVU
Diminished function (parenchymal
replacement hydronephrosis)
Absence of contrast excretion (renal vein
occlusion)
Necrotic part of tumour filled with
contrast media
NCCT
Unenhanced
CT scan shows
a 25-cm-
diameter soft-
tissue mass
deforming the
contour of the
right kidney
(arrow)
corticomedullary phase
Contrast-enhanced CT scan obtained during the corticomedullaryphase shows that the mass is hypoattenuatingcompared with the renal cortex and has peripheral enhancement (arrow) The cortex is brightly enhanced whereas the medulla is relatively unenhanced
nephrographic phase
Contrast-enhanced CT scan obtained during the nephrographicphase shows the hypervascularmass is well demarcated from the homogeneously enhancing renal parenchyma (arrow)
CT Scan of Left RCC
Heterogenous mass due to hemorrhagic necrosis
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
Cystic RCC
RCC invading renal vein
CT scan with 3D reconstruction
Neovascularity in Renal
Angiography
associated with RCC
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
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
Tumor Staging (Robson
System)
Tumor Staging (International
TNM Staging System)
Differential Diagnosis
bull Benign renal tumors
-Angiomyolipoma
bull Renal Pelvis Cancer
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
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)
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
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) lt1 often younger patients
worst prognosis
RENAL MEDULLARY CARCINOMA rare seen primarily in patients with sickle cell disease or sickle cell trait
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 ldquoclearrdquo
A variable proportion of cells with granular eosinophilic cytoplasm may be present
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
CLEAR CELL RENAL
CARCINOMAbull Contrast-enhanced CT scan
of a clear cell RCC shows an
expansile heterogeneously
enhancing right renal mass
(arrows) with associated
hypervascular retroperitoneal
lymphadenopathy
bullContrast-enhanced CT scan
obtained during the cortico-
medullary phase shows a
predominantly cystic clear cell
RCC (arrows) with peripheral
solid enhancing components
Clear Cell RCC
bullAxial gadolinium-
enhanced T1-
weighted MR
image obtained
during the
corticomedullary
phase shows a
small
homogeneously
enhancing
hypervascular
clear cell RCC
2 Multilocular Cystic RCC
multiseptated cystic RCC whose septa contain small clusters of clear cells
Multilocular cystic RCC is found in adults aged 20ndash76 years with a mean age of 51 years
Males predominate with a male-to-female ratio of 31
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
Multilocular Cystic RCC
Contrast-
enhanced
CT scan of
a
multilocular
cystic RCC
shows a
large
expansile
cystic
mass
3 Papillary RCC
second most common histologic subtype making up 10ndash15 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
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
Papillary RCC
bull Contrast-enhanced CT scan of a
papillary RCC shows a small
hypovascular mass (arrow) with
discrete foci of calcification
bullNon-enhanced CT scan of a
papillary RCC shows a
complex cystic mass with
hemorrhage (arrow) and
associated retroperitoneal
lymph-adenopathy
MRI
Axial T2-weighted MR image of a papillary RCC shows a round uniformly hypointensetumor (arrows) Note the multiple bilateral renal cysts (arrowheads)
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
Image Studies
Chromophobe RCC appears uniformly hyperechoic at ultrasonography
Despite their large size chromophobeRCCs demonstrate relatively homogeneous enhancement at CT and MR imaging
Chromophobe RCC may appear hypointense on T2-weighted MR images At catheter angiography chromophobeRCC is commonly hypovascular
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)
5 Collecting Duct
Carcinoma highly aggressive subtype of RCC that accounts for
lt1 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 21
The age range is 13ndash83 years (mean age 55 years)
typically appears as a gray-white infiltrative neoplasm with its epicenter in the pelvicalicealsystem
characterized by an infiltrative growth pattern at imaging
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
Collecting Duct Carcinoma
Power Doppler
sonogram of a
collecting duct
carcinoma shows a
solid hypovascular
medullary neoplasm
(arrows)
CECT
Contrast-enhanced
CT scan of a
collecting duct
carcinoma shows a
heterogeneously
enhancing left renal
mass (arrows) with
prominent
calcifications
(arrowheads)
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 21
appears as an infiltrative heterogeneous mass with a medullary epicenter
Manifests as an infiltrative heterogeneous medullaryneoplasm
Hemorrhage and necrosis contribute to tumor heterogeneity
Renal medullary carcinoma is typically associated with caliectasis
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
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)
Imaging of RCC
Ultrasonography
Intravenous Urography (IVU)
CT scanning more sensitive mass+renalhilum perinephric space and vena cava adrenals regional LN and adjacent organs
Renal Angiography
MRI to evaluate collecting system and IVC involvement
ULTRASONOGRAPHY
USG
Hyper echoic mostly in small tumors lt3
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
IVU of Right RCC
IVU
Diminished function (parenchymal
replacement hydronephrosis)
Absence of contrast excretion (renal vein
occlusion)
Necrotic part of tumour filled with
contrast media
NCCT
Unenhanced
CT scan shows
a 25-cm-
diameter soft-
tissue mass
deforming the
contour of the
right kidney
(arrow)
corticomedullary phase
Contrast-enhanced CT scan obtained during the corticomedullaryphase shows that the mass is hypoattenuatingcompared with the renal cortex and has peripheral enhancement (arrow) The cortex is brightly enhanced whereas the medulla is relatively unenhanced
nephrographic phase
Contrast-enhanced CT scan obtained during the nephrographicphase shows the hypervascularmass is well demarcated from the homogeneously enhancing renal parenchyma (arrow)
CT Scan of Left RCC
Heterogenous mass due to hemorrhagic necrosis
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
Cystic RCC
RCC invading renal vein
CT scan with 3D reconstruction
Neovascularity in Renal
Angiography
associated with RCC
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
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
Tumor Staging (Robson
System)
Tumor Staging (International
TNM Staging System)
Differential Diagnosis
bull Benign renal tumors
-Angiomyolipoma
bull Renal Pelvis Cancer
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)
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
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) lt1 often younger patients
worst prognosis
RENAL MEDULLARY CARCINOMA rare seen primarily in patients with sickle cell disease or sickle cell trait
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 ldquoclearrdquo
A variable proportion of cells with granular eosinophilic cytoplasm may be present
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
CLEAR CELL RENAL
CARCINOMAbull Contrast-enhanced CT scan
of a clear cell RCC shows an
expansile heterogeneously
enhancing right renal mass
(arrows) with associated
hypervascular retroperitoneal
lymphadenopathy
bullContrast-enhanced CT scan
obtained during the cortico-
medullary phase shows a
predominantly cystic clear cell
RCC (arrows) with peripheral
solid enhancing components
Clear Cell RCC
bullAxial gadolinium-
enhanced T1-
weighted MR
image obtained
during the
corticomedullary
phase shows a
small
homogeneously
enhancing
hypervascular
clear cell RCC
2 Multilocular Cystic RCC
multiseptated cystic RCC whose septa contain small clusters of clear cells
Multilocular cystic RCC is found in adults aged 20ndash76 years with a mean age of 51 years
Males predominate with a male-to-female ratio of 31
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
Multilocular Cystic RCC
Contrast-
enhanced
CT scan of
a
multilocular
cystic RCC
shows a
large
expansile
cystic
mass
3 Papillary RCC
second most common histologic subtype making up 10ndash15 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
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
Papillary RCC
bull Contrast-enhanced CT scan of a
papillary RCC shows a small
hypovascular mass (arrow) with
discrete foci of calcification
bullNon-enhanced CT scan of a
papillary RCC shows a
complex cystic mass with
hemorrhage (arrow) and
associated retroperitoneal
lymph-adenopathy
MRI
Axial T2-weighted MR image of a papillary RCC shows a round uniformly hypointensetumor (arrows) Note the multiple bilateral renal cysts (arrowheads)
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
Image Studies
Chromophobe RCC appears uniformly hyperechoic at ultrasonography
Despite their large size chromophobeRCCs demonstrate relatively homogeneous enhancement at CT and MR imaging
Chromophobe RCC may appear hypointense on T2-weighted MR images At catheter angiography chromophobeRCC is commonly hypovascular
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)
5 Collecting Duct
Carcinoma highly aggressive subtype of RCC that accounts for
lt1 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 21
The age range is 13ndash83 years (mean age 55 years)
typically appears as a gray-white infiltrative neoplasm with its epicenter in the pelvicalicealsystem
characterized by an infiltrative growth pattern at imaging
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
Collecting Duct Carcinoma
Power Doppler
sonogram of a
collecting duct
carcinoma shows a
solid hypovascular
medullary neoplasm
(arrows)
CECT
Contrast-enhanced
CT scan of a
collecting duct
carcinoma shows a
heterogeneously
enhancing left renal
mass (arrows) with
prominent
calcifications
(arrowheads)
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 21
appears as an infiltrative heterogeneous mass with a medullary epicenter
Manifests as an infiltrative heterogeneous medullaryneoplasm
Hemorrhage and necrosis contribute to tumor heterogeneity
Renal medullary carcinoma is typically associated with caliectasis
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
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)
Imaging of RCC
Ultrasonography
Intravenous Urography (IVU)
CT scanning more sensitive mass+renalhilum perinephric space and vena cava adrenals regional LN and adjacent organs
Renal Angiography
MRI to evaluate collecting system and IVC involvement
ULTRASONOGRAPHY
USG
Hyper echoic mostly in small tumors lt3
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
IVU of Right RCC
IVU
Diminished function (parenchymal
replacement hydronephrosis)
Absence of contrast excretion (renal vein
occlusion)
Necrotic part of tumour filled with
contrast media
NCCT
Unenhanced
CT scan shows
a 25-cm-
diameter soft-
tissue mass
deforming the
contour of the
right kidney
(arrow)
corticomedullary phase
Contrast-enhanced CT scan obtained during the corticomedullaryphase shows that the mass is hypoattenuatingcompared with the renal cortex and has peripheral enhancement (arrow) The cortex is brightly enhanced whereas the medulla is relatively unenhanced
nephrographic phase
Contrast-enhanced CT scan obtained during the nephrographicphase shows the hypervascularmass is well demarcated from the homogeneously enhancing renal parenchyma (arrow)
CT Scan of Left RCC
Heterogenous mass due to hemorrhagic necrosis
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
Cystic RCC
RCC invading renal vein
CT scan with 3D reconstruction
Neovascularity in Renal
Angiography
associated with RCC
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
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
Tumor Staging (Robson
System)
Tumor Staging (International
TNM Staging System)
Differential Diagnosis
bull Benign renal tumors
-Angiomyolipoma
bull Renal Pelvis Cancer
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
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) lt1 often younger patients
worst prognosis
RENAL MEDULLARY CARCINOMA rare seen primarily in patients with sickle cell disease or sickle cell trait
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 ldquoclearrdquo
A variable proportion of cells with granular eosinophilic cytoplasm may be present
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
CLEAR CELL RENAL
CARCINOMAbull Contrast-enhanced CT scan
of a clear cell RCC shows an
expansile heterogeneously
enhancing right renal mass
(arrows) with associated
hypervascular retroperitoneal
lymphadenopathy
bullContrast-enhanced CT scan
obtained during the cortico-
medullary phase shows a
predominantly cystic clear cell
RCC (arrows) with peripheral
solid enhancing components
Clear Cell RCC
bullAxial gadolinium-
enhanced T1-
weighted MR
image obtained
during the
corticomedullary
phase shows a
small
homogeneously
enhancing
hypervascular
clear cell RCC
2 Multilocular Cystic RCC
multiseptated cystic RCC whose septa contain small clusters of clear cells
Multilocular cystic RCC is found in adults aged 20ndash76 years with a mean age of 51 years
Males predominate with a male-to-female ratio of 31
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
Multilocular Cystic RCC
Contrast-
enhanced
CT scan of
a
multilocular
cystic RCC
shows a
large
expansile
cystic
mass
3 Papillary RCC
second most common histologic subtype making up 10ndash15 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
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
Papillary RCC
bull Contrast-enhanced CT scan of a
papillary RCC shows a small
hypovascular mass (arrow) with
discrete foci of calcification
bullNon-enhanced CT scan of a
papillary RCC shows a
complex cystic mass with
hemorrhage (arrow) and
associated retroperitoneal
lymph-adenopathy
MRI
Axial T2-weighted MR image of a papillary RCC shows a round uniformly hypointensetumor (arrows) Note the multiple bilateral renal cysts (arrowheads)
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
Image Studies
Chromophobe RCC appears uniformly hyperechoic at ultrasonography
Despite their large size chromophobeRCCs demonstrate relatively homogeneous enhancement at CT and MR imaging
Chromophobe RCC may appear hypointense on T2-weighted MR images At catheter angiography chromophobeRCC is commonly hypovascular
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)
5 Collecting Duct
Carcinoma highly aggressive subtype of RCC that accounts for
lt1 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 21
The age range is 13ndash83 years (mean age 55 years)
typically appears as a gray-white infiltrative neoplasm with its epicenter in the pelvicalicealsystem
characterized by an infiltrative growth pattern at imaging
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
Collecting Duct Carcinoma
Power Doppler
sonogram of a
collecting duct
carcinoma shows a
solid hypovascular
medullary neoplasm
(arrows)
CECT
Contrast-enhanced
CT scan of a
collecting duct
carcinoma shows a
heterogeneously
enhancing left renal
mass (arrows) with
prominent
calcifications
(arrowheads)
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 21
appears as an infiltrative heterogeneous mass with a medullary epicenter
Manifests as an infiltrative heterogeneous medullaryneoplasm
Hemorrhage and necrosis contribute to tumor heterogeneity
Renal medullary carcinoma is typically associated with caliectasis
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
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)
Imaging of RCC
Ultrasonography
Intravenous Urography (IVU)
CT scanning more sensitive mass+renalhilum perinephric space and vena cava adrenals regional LN and adjacent organs
Renal Angiography
MRI to evaluate collecting system and IVC involvement
ULTRASONOGRAPHY
USG
Hyper echoic mostly in small tumors lt3
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
IVU of Right RCC
IVU
Diminished function (parenchymal
replacement hydronephrosis)
Absence of contrast excretion (renal vein
occlusion)
Necrotic part of tumour filled with
contrast media
NCCT
Unenhanced
CT scan shows
a 25-cm-
diameter soft-
tissue mass
deforming the
contour of the
right kidney
(arrow)
corticomedullary phase
Contrast-enhanced CT scan obtained during the corticomedullaryphase shows that the mass is hypoattenuatingcompared with the renal cortex and has peripheral enhancement (arrow) The cortex is brightly enhanced whereas the medulla is relatively unenhanced
nephrographic phase
Contrast-enhanced CT scan obtained during the nephrographicphase shows the hypervascularmass is well demarcated from the homogeneously enhancing renal parenchyma (arrow)
CT Scan of Left RCC
Heterogenous mass due to hemorrhagic necrosis
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
Cystic RCC
RCC invading renal vein
CT scan with 3D reconstruction
Neovascularity in Renal
Angiography
associated with RCC
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
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
Tumor Staging (Robson
System)
Tumor Staging (International
TNM Staging System)
Differential Diagnosis
bull Benign renal tumors
-Angiomyolipoma
bull Renal Pelvis Cancer
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) lt1 often younger patients
worst prognosis
RENAL MEDULLARY CARCINOMA rare seen primarily in patients with sickle cell disease or sickle cell trait
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 ldquoclearrdquo
A variable proportion of cells with granular eosinophilic cytoplasm may be present
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
CLEAR CELL RENAL
CARCINOMAbull Contrast-enhanced CT scan
of a clear cell RCC shows an
expansile heterogeneously
enhancing right renal mass
(arrows) with associated
hypervascular retroperitoneal
lymphadenopathy
bullContrast-enhanced CT scan
obtained during the cortico-
medullary phase shows a
predominantly cystic clear cell
RCC (arrows) with peripheral
solid enhancing components
Clear Cell RCC
bullAxial gadolinium-
enhanced T1-
weighted MR
image obtained
during the
corticomedullary
phase shows a
small
homogeneously
enhancing
hypervascular
clear cell RCC
2 Multilocular Cystic RCC
multiseptated cystic RCC whose septa contain small clusters of clear cells
Multilocular cystic RCC is found in adults aged 20ndash76 years with a mean age of 51 years
Males predominate with a male-to-female ratio of 31
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
Multilocular Cystic RCC
Contrast-
enhanced
CT scan of
a
multilocular
cystic RCC
shows a
large
expansile
cystic
mass
3 Papillary RCC
second most common histologic subtype making up 10ndash15 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
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
Papillary RCC
bull Contrast-enhanced CT scan of a
papillary RCC shows a small
hypovascular mass (arrow) with
discrete foci of calcification
bullNon-enhanced CT scan of a
papillary RCC shows a
complex cystic mass with
hemorrhage (arrow) and
associated retroperitoneal
lymph-adenopathy
MRI
Axial T2-weighted MR image of a papillary RCC shows a round uniformly hypointensetumor (arrows) Note the multiple bilateral renal cysts (arrowheads)
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
Image Studies
Chromophobe RCC appears uniformly hyperechoic at ultrasonography
Despite their large size chromophobeRCCs demonstrate relatively homogeneous enhancement at CT and MR imaging
Chromophobe RCC may appear hypointense on T2-weighted MR images At catheter angiography chromophobeRCC is commonly hypovascular
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)
5 Collecting Duct
Carcinoma highly aggressive subtype of RCC that accounts for
lt1 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 21
The age range is 13ndash83 years (mean age 55 years)
typically appears as a gray-white infiltrative neoplasm with its epicenter in the pelvicalicealsystem
characterized by an infiltrative growth pattern at imaging
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
Collecting Duct Carcinoma
Power Doppler
sonogram of a
collecting duct
carcinoma shows a
solid hypovascular
medullary neoplasm
(arrows)
CECT
Contrast-enhanced
CT scan of a
collecting duct
carcinoma shows a
heterogeneously
enhancing left renal
mass (arrows) with
prominent
calcifications
(arrowheads)
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 21
appears as an infiltrative heterogeneous mass with a medullary epicenter
Manifests as an infiltrative heterogeneous medullaryneoplasm
Hemorrhage and necrosis contribute to tumor heterogeneity
Renal medullary carcinoma is typically associated with caliectasis
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
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)
Imaging of RCC
Ultrasonography
Intravenous Urography (IVU)
CT scanning more sensitive mass+renalhilum perinephric space and vena cava adrenals regional LN and adjacent organs
Renal Angiography
MRI to evaluate collecting system and IVC involvement
ULTRASONOGRAPHY
USG
Hyper echoic mostly in small tumors lt3
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
IVU of Right RCC
IVU
Diminished function (parenchymal
replacement hydronephrosis)
Absence of contrast excretion (renal vein
occlusion)
Necrotic part of tumour filled with
contrast media
NCCT
Unenhanced
CT scan shows
a 25-cm-
diameter soft-
tissue mass
deforming the
contour of the
right kidney
(arrow)
corticomedullary phase
Contrast-enhanced CT scan obtained during the corticomedullaryphase shows that the mass is hypoattenuatingcompared with the renal cortex and has peripheral enhancement (arrow) The cortex is brightly enhanced whereas the medulla is relatively unenhanced
nephrographic phase
Contrast-enhanced CT scan obtained during the nephrographicphase shows the hypervascularmass is well demarcated from the homogeneously enhancing renal parenchyma (arrow)
CT Scan of Left RCC
Heterogenous mass due to hemorrhagic necrosis
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
Cystic RCC
RCC invading renal vein
CT scan with 3D reconstruction
Neovascularity in Renal
Angiography
associated with RCC
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
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
Tumor Staging (Robson
System)
Tumor Staging (International
TNM Staging System)
Differential Diagnosis
bull Benign renal tumors
-Angiomyolipoma
bull Renal Pelvis Cancer
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 ldquoclearrdquo
A variable proportion of cells with granular eosinophilic cytoplasm may be present
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
CLEAR CELL RENAL
CARCINOMAbull Contrast-enhanced CT scan
of a clear cell RCC shows an
expansile heterogeneously
enhancing right renal mass
(arrows) with associated
hypervascular retroperitoneal
lymphadenopathy
bullContrast-enhanced CT scan
obtained during the cortico-
medullary phase shows a
predominantly cystic clear cell
RCC (arrows) with peripheral
solid enhancing components
Clear Cell RCC
bullAxial gadolinium-
enhanced T1-
weighted MR
image obtained
during the
corticomedullary
phase shows a
small
homogeneously
enhancing
hypervascular
clear cell RCC
2 Multilocular Cystic RCC
multiseptated cystic RCC whose septa contain small clusters of clear cells
Multilocular cystic RCC is found in adults aged 20ndash76 years with a mean age of 51 years
Males predominate with a male-to-female ratio of 31
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
Multilocular Cystic RCC
Contrast-
enhanced
CT scan of
a
multilocular
cystic RCC
shows a
large
expansile
cystic
mass
3 Papillary RCC
second most common histologic subtype making up 10ndash15 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
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
Papillary RCC
bull Contrast-enhanced CT scan of a
papillary RCC shows a small
hypovascular mass (arrow) with
discrete foci of calcification
bullNon-enhanced CT scan of a
papillary RCC shows a
complex cystic mass with
hemorrhage (arrow) and
associated retroperitoneal
lymph-adenopathy
MRI
Axial T2-weighted MR image of a papillary RCC shows a round uniformly hypointensetumor (arrows) Note the multiple bilateral renal cysts (arrowheads)
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
Image Studies
Chromophobe RCC appears uniformly hyperechoic at ultrasonography
Despite their large size chromophobeRCCs demonstrate relatively homogeneous enhancement at CT and MR imaging
Chromophobe RCC may appear hypointense on T2-weighted MR images At catheter angiography chromophobeRCC is commonly hypovascular
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)
5 Collecting Duct
Carcinoma highly aggressive subtype of RCC that accounts for
lt1 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 21
The age range is 13ndash83 years (mean age 55 years)
typically appears as a gray-white infiltrative neoplasm with its epicenter in the pelvicalicealsystem
characterized by an infiltrative growth pattern at imaging
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
Collecting Duct Carcinoma
Power Doppler
sonogram of a
collecting duct
carcinoma shows a
solid hypovascular
medullary neoplasm
(arrows)
CECT
Contrast-enhanced
CT scan of a
collecting duct
carcinoma shows a
heterogeneously
enhancing left renal
mass (arrows) with
prominent
calcifications
(arrowheads)
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 21
appears as an infiltrative heterogeneous mass with a medullary epicenter
Manifests as an infiltrative heterogeneous medullaryneoplasm
Hemorrhage and necrosis contribute to tumor heterogeneity
Renal medullary carcinoma is typically associated with caliectasis
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
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)
Imaging of RCC
Ultrasonography
Intravenous Urography (IVU)
CT scanning more sensitive mass+renalhilum perinephric space and vena cava adrenals regional LN and adjacent organs
Renal Angiography
MRI to evaluate collecting system and IVC involvement
ULTRASONOGRAPHY
USG
Hyper echoic mostly in small tumors lt3
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
IVU of Right RCC
IVU
Diminished function (parenchymal
replacement hydronephrosis)
Absence of contrast excretion (renal vein
occlusion)
Necrotic part of tumour filled with
contrast media
NCCT
Unenhanced
CT scan shows
a 25-cm-
diameter soft-
tissue mass
deforming the
contour of the
right kidney
(arrow)
corticomedullary phase
Contrast-enhanced CT scan obtained during the corticomedullaryphase shows that the mass is hypoattenuatingcompared with the renal cortex and has peripheral enhancement (arrow) The cortex is brightly enhanced whereas the medulla is relatively unenhanced
nephrographic phase
Contrast-enhanced CT scan obtained during the nephrographicphase shows the hypervascularmass is well demarcated from the homogeneously enhancing renal parenchyma (arrow)
CT Scan of Left RCC
Heterogenous mass due to hemorrhagic necrosis
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
Cystic RCC
RCC invading renal vein
CT scan with 3D reconstruction
Neovascularity in Renal
Angiography
associated with RCC
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
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
Tumor Staging (Robson
System)
Tumor Staging (International
TNM Staging System)
Differential Diagnosis
bull Benign renal tumors
-Angiomyolipoma
bull Renal Pelvis Cancer
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
CLEAR CELL RENAL
CARCINOMAbull Contrast-enhanced CT scan
of a clear cell RCC shows an
expansile heterogeneously
enhancing right renal mass
(arrows) with associated
hypervascular retroperitoneal
lymphadenopathy
bullContrast-enhanced CT scan
obtained during the cortico-
medullary phase shows a
predominantly cystic clear cell
RCC (arrows) with peripheral
solid enhancing components
Clear Cell RCC
bullAxial gadolinium-
enhanced T1-
weighted MR
image obtained
during the
corticomedullary
phase shows a
small
homogeneously
enhancing
hypervascular
clear cell RCC
2 Multilocular Cystic RCC
multiseptated cystic RCC whose septa contain small clusters of clear cells
Multilocular cystic RCC is found in adults aged 20ndash76 years with a mean age of 51 years
Males predominate with a male-to-female ratio of 31
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
Multilocular Cystic RCC
Contrast-
enhanced
CT scan of
a
multilocular
cystic RCC
shows a
large
expansile
cystic
mass
3 Papillary RCC
second most common histologic subtype making up 10ndash15 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
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
Papillary RCC
bull Contrast-enhanced CT scan of a
papillary RCC shows a small
hypovascular mass (arrow) with
discrete foci of calcification
bullNon-enhanced CT scan of a
papillary RCC shows a
complex cystic mass with
hemorrhage (arrow) and
associated retroperitoneal
lymph-adenopathy
MRI
Axial T2-weighted MR image of a papillary RCC shows a round uniformly hypointensetumor (arrows) Note the multiple bilateral renal cysts (arrowheads)
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
Image Studies
Chromophobe RCC appears uniformly hyperechoic at ultrasonography
Despite their large size chromophobeRCCs demonstrate relatively homogeneous enhancement at CT and MR imaging
Chromophobe RCC may appear hypointense on T2-weighted MR images At catheter angiography chromophobeRCC is commonly hypovascular
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)
5 Collecting Duct
Carcinoma highly aggressive subtype of RCC that accounts for
lt1 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 21
The age range is 13ndash83 years (mean age 55 years)
typically appears as a gray-white infiltrative neoplasm with its epicenter in the pelvicalicealsystem
characterized by an infiltrative growth pattern at imaging
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
Collecting Duct Carcinoma
Power Doppler
sonogram of a
collecting duct
carcinoma shows a
solid hypovascular
medullary neoplasm
(arrows)
CECT
Contrast-enhanced
CT scan of a
collecting duct
carcinoma shows a
heterogeneously
enhancing left renal
mass (arrows) with
prominent
calcifications
(arrowheads)
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 21
appears as an infiltrative heterogeneous mass with a medullary epicenter
Manifests as an infiltrative heterogeneous medullaryneoplasm
Hemorrhage and necrosis contribute to tumor heterogeneity
Renal medullary carcinoma is typically associated with caliectasis
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
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)
Imaging of RCC
Ultrasonography
Intravenous Urography (IVU)
CT scanning more sensitive mass+renalhilum perinephric space and vena cava adrenals regional LN and adjacent organs
Renal Angiography
MRI to evaluate collecting system and IVC involvement
ULTRASONOGRAPHY
USG
Hyper echoic mostly in small tumors lt3
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
IVU of Right RCC
IVU
Diminished function (parenchymal
replacement hydronephrosis)
Absence of contrast excretion (renal vein
occlusion)
Necrotic part of tumour filled with
contrast media
NCCT
Unenhanced
CT scan shows
a 25-cm-
diameter soft-
tissue mass
deforming the
contour of the
right kidney
(arrow)
corticomedullary phase
Contrast-enhanced CT scan obtained during the corticomedullaryphase shows that the mass is hypoattenuatingcompared with the renal cortex and has peripheral enhancement (arrow) The cortex is brightly enhanced whereas the medulla is relatively unenhanced
nephrographic phase
Contrast-enhanced CT scan obtained during the nephrographicphase shows the hypervascularmass is well demarcated from the homogeneously enhancing renal parenchyma (arrow)
CT Scan of Left RCC
Heterogenous mass due to hemorrhagic necrosis
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
Cystic RCC
RCC invading renal vein
CT scan with 3D reconstruction
Neovascularity in Renal
Angiography
associated with RCC
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
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
Tumor Staging (Robson
System)
Tumor Staging (International
TNM Staging System)
Differential Diagnosis
bull Benign renal tumors
-Angiomyolipoma
bull Renal Pelvis Cancer
CLEAR CELL RENAL
CARCINOMAbull Contrast-enhanced CT scan
of a clear cell RCC shows an
expansile heterogeneously
enhancing right renal mass
(arrows) with associated
hypervascular retroperitoneal
lymphadenopathy
bullContrast-enhanced CT scan
obtained during the cortico-
medullary phase shows a
predominantly cystic clear cell
RCC (arrows) with peripheral
solid enhancing components
Clear Cell RCC
bullAxial gadolinium-
enhanced T1-
weighted MR
image obtained
during the
corticomedullary
phase shows a
small
homogeneously
enhancing
hypervascular
clear cell RCC
2 Multilocular Cystic RCC
multiseptated cystic RCC whose septa contain small clusters of clear cells
Multilocular cystic RCC is found in adults aged 20ndash76 years with a mean age of 51 years
Males predominate with a male-to-female ratio of 31
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
Multilocular Cystic RCC
Contrast-
enhanced
CT scan of
a
multilocular
cystic RCC
shows a
large
expansile
cystic
mass
3 Papillary RCC
second most common histologic subtype making up 10ndash15 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
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
Papillary RCC
bull Contrast-enhanced CT scan of a
papillary RCC shows a small
hypovascular mass (arrow) with
discrete foci of calcification
bullNon-enhanced CT scan of a
papillary RCC shows a
complex cystic mass with
hemorrhage (arrow) and
associated retroperitoneal
lymph-adenopathy
MRI
Axial T2-weighted MR image of a papillary RCC shows a round uniformly hypointensetumor (arrows) Note the multiple bilateral renal cysts (arrowheads)
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
Image Studies
Chromophobe RCC appears uniformly hyperechoic at ultrasonography
Despite their large size chromophobeRCCs demonstrate relatively homogeneous enhancement at CT and MR imaging
Chromophobe RCC may appear hypointense on T2-weighted MR images At catheter angiography chromophobeRCC is commonly hypovascular
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)
5 Collecting Duct
Carcinoma highly aggressive subtype of RCC that accounts for
lt1 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 21
The age range is 13ndash83 years (mean age 55 years)
typically appears as a gray-white infiltrative neoplasm with its epicenter in the pelvicalicealsystem
characterized by an infiltrative growth pattern at imaging
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
Collecting Duct Carcinoma
Power Doppler
sonogram of a
collecting duct
carcinoma shows a
solid hypovascular
medullary neoplasm
(arrows)
CECT
Contrast-enhanced
CT scan of a
collecting duct
carcinoma shows a
heterogeneously
enhancing left renal
mass (arrows) with
prominent
calcifications
(arrowheads)
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 21
appears as an infiltrative heterogeneous mass with a medullary epicenter
Manifests as an infiltrative heterogeneous medullaryneoplasm
Hemorrhage and necrosis contribute to tumor heterogeneity
Renal medullary carcinoma is typically associated with caliectasis
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
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)
Imaging of RCC
Ultrasonography
Intravenous Urography (IVU)
CT scanning more sensitive mass+renalhilum perinephric space and vena cava adrenals regional LN and adjacent organs
Renal Angiography
MRI to evaluate collecting system and IVC involvement
ULTRASONOGRAPHY
USG
Hyper echoic mostly in small tumors lt3
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
IVU of Right RCC
IVU
Diminished function (parenchymal
replacement hydronephrosis)
Absence of contrast excretion (renal vein
occlusion)
Necrotic part of tumour filled with
contrast media
NCCT
Unenhanced
CT scan shows
a 25-cm-
diameter soft-
tissue mass
deforming the
contour of the
right kidney
(arrow)
corticomedullary phase
Contrast-enhanced CT scan obtained during the corticomedullaryphase shows that the mass is hypoattenuatingcompared with the renal cortex and has peripheral enhancement (arrow) The cortex is brightly enhanced whereas the medulla is relatively unenhanced
nephrographic phase
Contrast-enhanced CT scan obtained during the nephrographicphase shows the hypervascularmass is well demarcated from the homogeneously enhancing renal parenchyma (arrow)
CT Scan of Left RCC
Heterogenous mass due to hemorrhagic necrosis
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
Cystic RCC
RCC invading renal vein
CT scan with 3D reconstruction
Neovascularity in Renal
Angiography
associated with RCC
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
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
Tumor Staging (Robson
System)
Tumor Staging (International
TNM Staging System)
Differential Diagnosis
bull Benign renal tumors
-Angiomyolipoma
bull Renal Pelvis Cancer
Clear Cell RCC
bullAxial gadolinium-
enhanced T1-
weighted MR
image obtained
during the
corticomedullary
phase shows a
small
homogeneously
enhancing
hypervascular
clear cell RCC
2 Multilocular Cystic RCC
multiseptated cystic RCC whose septa contain small clusters of clear cells
Multilocular cystic RCC is found in adults aged 20ndash76 years with a mean age of 51 years
Males predominate with a male-to-female ratio of 31
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
Multilocular Cystic RCC
Contrast-
enhanced
CT scan of
a
multilocular
cystic RCC
shows a
large
expansile
cystic
mass
3 Papillary RCC
second most common histologic subtype making up 10ndash15 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
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
Papillary RCC
bull Contrast-enhanced CT scan of a
papillary RCC shows a small
hypovascular mass (arrow) with
discrete foci of calcification
bullNon-enhanced CT scan of a
papillary RCC shows a
complex cystic mass with
hemorrhage (arrow) and
associated retroperitoneal
lymph-adenopathy
MRI
Axial T2-weighted MR image of a papillary RCC shows a round uniformly hypointensetumor (arrows) Note the multiple bilateral renal cysts (arrowheads)
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
Image Studies
Chromophobe RCC appears uniformly hyperechoic at ultrasonography
Despite their large size chromophobeRCCs demonstrate relatively homogeneous enhancement at CT and MR imaging
Chromophobe RCC may appear hypointense on T2-weighted MR images At catheter angiography chromophobeRCC is commonly hypovascular
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)
5 Collecting Duct
Carcinoma highly aggressive subtype of RCC that accounts for
lt1 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 21
The age range is 13ndash83 years (mean age 55 years)
typically appears as a gray-white infiltrative neoplasm with its epicenter in the pelvicalicealsystem
characterized by an infiltrative growth pattern at imaging
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
Collecting Duct Carcinoma
Power Doppler
sonogram of a
collecting duct
carcinoma shows a
solid hypovascular
medullary neoplasm
(arrows)
CECT
Contrast-enhanced
CT scan of a
collecting duct
carcinoma shows a
heterogeneously
enhancing left renal
mass (arrows) with
prominent
calcifications
(arrowheads)
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 21
appears as an infiltrative heterogeneous mass with a medullary epicenter
Manifests as an infiltrative heterogeneous medullaryneoplasm
Hemorrhage and necrosis contribute to tumor heterogeneity
Renal medullary carcinoma is typically associated with caliectasis
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
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)
Imaging of RCC
Ultrasonography
Intravenous Urography (IVU)
CT scanning more sensitive mass+renalhilum perinephric space and vena cava adrenals regional LN and adjacent organs
Renal Angiography
MRI to evaluate collecting system and IVC involvement
ULTRASONOGRAPHY
USG
Hyper echoic mostly in small tumors lt3
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
IVU of Right RCC
IVU
Diminished function (parenchymal
replacement hydronephrosis)
Absence of contrast excretion (renal vein
occlusion)
Necrotic part of tumour filled with
contrast media
NCCT
Unenhanced
CT scan shows
a 25-cm-
diameter soft-
tissue mass
deforming the
contour of the
right kidney
(arrow)
corticomedullary phase
Contrast-enhanced CT scan obtained during the corticomedullaryphase shows that the mass is hypoattenuatingcompared with the renal cortex and has peripheral enhancement (arrow) The cortex is brightly enhanced whereas the medulla is relatively unenhanced
nephrographic phase
Contrast-enhanced CT scan obtained during the nephrographicphase shows the hypervascularmass is well demarcated from the homogeneously enhancing renal parenchyma (arrow)
CT Scan of Left RCC
Heterogenous mass due to hemorrhagic necrosis
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
Cystic RCC
RCC invading renal vein
CT scan with 3D reconstruction
Neovascularity in Renal
Angiography
associated with RCC
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
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
Tumor Staging (Robson
System)
Tumor Staging (International
TNM Staging System)
Differential Diagnosis
bull Benign renal tumors
-Angiomyolipoma
bull Renal Pelvis Cancer
2 Multilocular Cystic RCC
multiseptated cystic RCC whose septa contain small clusters of clear cells
Multilocular cystic RCC is found in adults aged 20ndash76 years with a mean age of 51 years
Males predominate with a male-to-female ratio of 31
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
Multilocular Cystic RCC
Contrast-
enhanced
CT scan of
a
multilocular
cystic RCC
shows a
large
expansile
cystic
mass
3 Papillary RCC
second most common histologic subtype making up 10ndash15 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
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
Papillary RCC
bull Contrast-enhanced CT scan of a
papillary RCC shows a small
hypovascular mass (arrow) with
discrete foci of calcification
bullNon-enhanced CT scan of a
papillary RCC shows a
complex cystic mass with
hemorrhage (arrow) and
associated retroperitoneal
lymph-adenopathy
MRI
Axial T2-weighted MR image of a papillary RCC shows a round uniformly hypointensetumor (arrows) Note the multiple bilateral renal cysts (arrowheads)
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
Image Studies
Chromophobe RCC appears uniformly hyperechoic at ultrasonography
Despite their large size chromophobeRCCs demonstrate relatively homogeneous enhancement at CT and MR imaging
Chromophobe RCC may appear hypointense on T2-weighted MR images At catheter angiography chromophobeRCC is commonly hypovascular
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)
5 Collecting Duct
Carcinoma highly aggressive subtype of RCC that accounts for
lt1 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 21
The age range is 13ndash83 years (mean age 55 years)
typically appears as a gray-white infiltrative neoplasm with its epicenter in the pelvicalicealsystem
characterized by an infiltrative growth pattern at imaging
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
Collecting Duct Carcinoma
Power Doppler
sonogram of a
collecting duct
carcinoma shows a
solid hypovascular
medullary neoplasm
(arrows)
CECT
Contrast-enhanced
CT scan of a
collecting duct
carcinoma shows a
heterogeneously
enhancing left renal
mass (arrows) with
prominent
calcifications
(arrowheads)
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 21
appears as an infiltrative heterogeneous mass with a medullary epicenter
Manifests as an infiltrative heterogeneous medullaryneoplasm
Hemorrhage and necrosis contribute to tumor heterogeneity
Renal medullary carcinoma is typically associated with caliectasis
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
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)
Imaging of RCC
Ultrasonography
Intravenous Urography (IVU)
CT scanning more sensitive mass+renalhilum perinephric space and vena cava adrenals regional LN and adjacent organs
Renal Angiography
MRI to evaluate collecting system and IVC involvement
ULTRASONOGRAPHY
USG
Hyper echoic mostly in small tumors lt3
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
IVU of Right RCC
IVU
Diminished function (parenchymal
replacement hydronephrosis)
Absence of contrast excretion (renal vein
occlusion)
Necrotic part of tumour filled with
contrast media
NCCT
Unenhanced
CT scan shows
a 25-cm-
diameter soft-
tissue mass
deforming the
contour of the
right kidney
(arrow)
corticomedullary phase
Contrast-enhanced CT scan obtained during the corticomedullaryphase shows that the mass is hypoattenuatingcompared with the renal cortex and has peripheral enhancement (arrow) The cortex is brightly enhanced whereas the medulla is relatively unenhanced
nephrographic phase
Contrast-enhanced CT scan obtained during the nephrographicphase shows the hypervascularmass is well demarcated from the homogeneously enhancing renal parenchyma (arrow)
CT Scan of Left RCC
Heterogenous mass due to hemorrhagic necrosis
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
Cystic RCC
RCC invading renal vein
CT scan with 3D reconstruction
Neovascularity in Renal
Angiography
associated with RCC
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
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
Tumor Staging (Robson
System)
Tumor Staging (International
TNM Staging System)
Differential Diagnosis
bull Benign renal tumors
-Angiomyolipoma
bull Renal Pelvis Cancer
Multilocular Cystic RCC
Contrast-
enhanced
CT scan of
a
multilocular
cystic RCC
shows a
large
expansile
cystic
mass
3 Papillary RCC
second most common histologic subtype making up 10ndash15 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
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
Papillary RCC
bull Contrast-enhanced CT scan of a
papillary RCC shows a small
hypovascular mass (arrow) with
discrete foci of calcification
bullNon-enhanced CT scan of a
papillary RCC shows a
complex cystic mass with
hemorrhage (arrow) and
associated retroperitoneal
lymph-adenopathy
MRI
Axial T2-weighted MR image of a papillary RCC shows a round uniformly hypointensetumor (arrows) Note the multiple bilateral renal cysts (arrowheads)
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
Image Studies
Chromophobe RCC appears uniformly hyperechoic at ultrasonography
Despite their large size chromophobeRCCs demonstrate relatively homogeneous enhancement at CT and MR imaging
Chromophobe RCC may appear hypointense on T2-weighted MR images At catheter angiography chromophobeRCC is commonly hypovascular
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)
5 Collecting Duct
Carcinoma highly aggressive subtype of RCC that accounts for
lt1 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 21
The age range is 13ndash83 years (mean age 55 years)
typically appears as a gray-white infiltrative neoplasm with its epicenter in the pelvicalicealsystem
characterized by an infiltrative growth pattern at imaging
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
Collecting Duct Carcinoma
Power Doppler
sonogram of a
collecting duct
carcinoma shows a
solid hypovascular
medullary neoplasm
(arrows)
CECT
Contrast-enhanced
CT scan of a
collecting duct
carcinoma shows a
heterogeneously
enhancing left renal
mass (arrows) with
prominent
calcifications
(arrowheads)
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 21
appears as an infiltrative heterogeneous mass with a medullary epicenter
Manifests as an infiltrative heterogeneous medullaryneoplasm
Hemorrhage and necrosis contribute to tumor heterogeneity
Renal medullary carcinoma is typically associated with caliectasis
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
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)
Imaging of RCC
Ultrasonography
Intravenous Urography (IVU)
CT scanning more sensitive mass+renalhilum perinephric space and vena cava adrenals regional LN and adjacent organs
Renal Angiography
MRI to evaluate collecting system and IVC involvement
ULTRASONOGRAPHY
USG
Hyper echoic mostly in small tumors lt3
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
IVU of Right RCC
IVU
Diminished function (parenchymal
replacement hydronephrosis)
Absence of contrast excretion (renal vein
occlusion)
Necrotic part of tumour filled with
contrast media
NCCT
Unenhanced
CT scan shows
a 25-cm-
diameter soft-
tissue mass
deforming the
contour of the
right kidney
(arrow)
corticomedullary phase
Contrast-enhanced CT scan obtained during the corticomedullaryphase shows that the mass is hypoattenuatingcompared with the renal cortex and has peripheral enhancement (arrow) The cortex is brightly enhanced whereas the medulla is relatively unenhanced
nephrographic phase
Contrast-enhanced CT scan obtained during the nephrographicphase shows the hypervascularmass is well demarcated from the homogeneously enhancing renal parenchyma (arrow)
CT Scan of Left RCC
Heterogenous mass due to hemorrhagic necrosis
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
Cystic RCC
RCC invading renal vein
CT scan with 3D reconstruction
Neovascularity in Renal
Angiography
associated with RCC
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
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
Tumor Staging (Robson
System)
Tumor Staging (International
TNM Staging System)
Differential Diagnosis
bull Benign renal tumors
-Angiomyolipoma
bull Renal Pelvis Cancer
3 Papillary RCC
second most common histologic subtype making up 10ndash15 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
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
Papillary RCC
bull Contrast-enhanced CT scan of a
papillary RCC shows a small
hypovascular mass (arrow) with
discrete foci of calcification
bullNon-enhanced CT scan of a
papillary RCC shows a
complex cystic mass with
hemorrhage (arrow) and
associated retroperitoneal
lymph-adenopathy
MRI
Axial T2-weighted MR image of a papillary RCC shows a round uniformly hypointensetumor (arrows) Note the multiple bilateral renal cysts (arrowheads)
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
Image Studies
Chromophobe RCC appears uniformly hyperechoic at ultrasonography
Despite their large size chromophobeRCCs demonstrate relatively homogeneous enhancement at CT and MR imaging
Chromophobe RCC may appear hypointense on T2-weighted MR images At catheter angiography chromophobeRCC is commonly hypovascular
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)
5 Collecting Duct
Carcinoma highly aggressive subtype of RCC that accounts for
lt1 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 21
The age range is 13ndash83 years (mean age 55 years)
typically appears as a gray-white infiltrative neoplasm with its epicenter in the pelvicalicealsystem
characterized by an infiltrative growth pattern at imaging
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
Collecting Duct Carcinoma
Power Doppler
sonogram of a
collecting duct
carcinoma shows a
solid hypovascular
medullary neoplasm
(arrows)
CECT
Contrast-enhanced
CT scan of a
collecting duct
carcinoma shows a
heterogeneously
enhancing left renal
mass (arrows) with
prominent
calcifications
(arrowheads)
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 21
appears as an infiltrative heterogeneous mass with a medullary epicenter
Manifests as an infiltrative heterogeneous medullaryneoplasm
Hemorrhage and necrosis contribute to tumor heterogeneity
Renal medullary carcinoma is typically associated with caliectasis
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
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)
Imaging of RCC
Ultrasonography
Intravenous Urography (IVU)
CT scanning more sensitive mass+renalhilum perinephric space and vena cava adrenals regional LN and adjacent organs
Renal Angiography
MRI to evaluate collecting system and IVC involvement
ULTRASONOGRAPHY
USG
Hyper echoic mostly in small tumors lt3
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
IVU of Right RCC
IVU
Diminished function (parenchymal
replacement hydronephrosis)
Absence of contrast excretion (renal vein
occlusion)
Necrotic part of tumour filled with
contrast media
NCCT
Unenhanced
CT scan shows
a 25-cm-
diameter soft-
tissue mass
deforming the
contour of the
right kidney
(arrow)
corticomedullary phase
Contrast-enhanced CT scan obtained during the corticomedullaryphase shows that the mass is hypoattenuatingcompared with the renal cortex and has peripheral enhancement (arrow) The cortex is brightly enhanced whereas the medulla is relatively unenhanced
nephrographic phase
Contrast-enhanced CT scan obtained during the nephrographicphase shows the hypervascularmass is well demarcated from the homogeneously enhancing renal parenchyma (arrow)
CT Scan of Left RCC
Heterogenous mass due to hemorrhagic necrosis
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
Cystic RCC
RCC invading renal vein
CT scan with 3D reconstruction
Neovascularity in Renal
Angiography
associated with RCC
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
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
Tumor Staging (Robson
System)
Tumor Staging (International
TNM Staging System)
Differential Diagnosis
bull Benign renal tumors
-Angiomyolipoma
bull Renal Pelvis Cancer
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
Papillary RCC
bull Contrast-enhanced CT scan of a
papillary RCC shows a small
hypovascular mass (arrow) with
discrete foci of calcification
bullNon-enhanced CT scan of a
papillary RCC shows a
complex cystic mass with
hemorrhage (arrow) and
associated retroperitoneal
lymph-adenopathy
MRI
Axial T2-weighted MR image of a papillary RCC shows a round uniformly hypointensetumor (arrows) Note the multiple bilateral renal cysts (arrowheads)
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
Image Studies
Chromophobe RCC appears uniformly hyperechoic at ultrasonography
Despite their large size chromophobeRCCs demonstrate relatively homogeneous enhancement at CT and MR imaging
Chromophobe RCC may appear hypointense on T2-weighted MR images At catheter angiography chromophobeRCC is commonly hypovascular
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)
5 Collecting Duct
Carcinoma highly aggressive subtype of RCC that accounts for
lt1 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 21
The age range is 13ndash83 years (mean age 55 years)
typically appears as a gray-white infiltrative neoplasm with its epicenter in the pelvicalicealsystem
characterized by an infiltrative growth pattern at imaging
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
Collecting Duct Carcinoma
Power Doppler
sonogram of a
collecting duct
carcinoma shows a
solid hypovascular
medullary neoplasm
(arrows)
CECT
Contrast-enhanced
CT scan of a
collecting duct
carcinoma shows a
heterogeneously
enhancing left renal
mass (arrows) with
prominent
calcifications
(arrowheads)
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 21
appears as an infiltrative heterogeneous mass with a medullary epicenter
Manifests as an infiltrative heterogeneous medullaryneoplasm
Hemorrhage and necrosis contribute to tumor heterogeneity
Renal medullary carcinoma is typically associated with caliectasis
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
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)
Imaging of RCC
Ultrasonography
Intravenous Urography (IVU)
CT scanning more sensitive mass+renalhilum perinephric space and vena cava adrenals regional LN and adjacent organs
Renal Angiography
MRI to evaluate collecting system and IVC involvement
ULTRASONOGRAPHY
USG
Hyper echoic mostly in small tumors lt3
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
IVU of Right RCC
IVU
Diminished function (parenchymal
replacement hydronephrosis)
Absence of contrast excretion (renal vein
occlusion)
Necrotic part of tumour filled with
contrast media
NCCT
Unenhanced
CT scan shows
a 25-cm-
diameter soft-
tissue mass
deforming the
contour of the
right kidney
(arrow)
corticomedullary phase
Contrast-enhanced CT scan obtained during the corticomedullaryphase shows that the mass is hypoattenuatingcompared with the renal cortex and has peripheral enhancement (arrow) The cortex is brightly enhanced whereas the medulla is relatively unenhanced
nephrographic phase
Contrast-enhanced CT scan obtained during the nephrographicphase shows the hypervascularmass is well demarcated from the homogeneously enhancing renal parenchyma (arrow)
CT Scan of Left RCC
Heterogenous mass due to hemorrhagic necrosis
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
Cystic RCC
RCC invading renal vein
CT scan with 3D reconstruction
Neovascularity in Renal
Angiography
associated with RCC
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
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
Tumor Staging (Robson
System)
Tumor Staging (International
TNM Staging System)
Differential Diagnosis
bull Benign renal tumors
-Angiomyolipoma
bull Renal Pelvis Cancer
Papillary RCC
bull Contrast-enhanced CT scan of a
papillary RCC shows a small
hypovascular mass (arrow) with
discrete foci of calcification
bullNon-enhanced CT scan of a
papillary RCC shows a
complex cystic mass with
hemorrhage (arrow) and
associated retroperitoneal
lymph-adenopathy
MRI
Axial T2-weighted MR image of a papillary RCC shows a round uniformly hypointensetumor (arrows) Note the multiple bilateral renal cysts (arrowheads)
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
Image Studies
Chromophobe RCC appears uniformly hyperechoic at ultrasonography
Despite their large size chromophobeRCCs demonstrate relatively homogeneous enhancement at CT and MR imaging
Chromophobe RCC may appear hypointense on T2-weighted MR images At catheter angiography chromophobeRCC is commonly hypovascular
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)
5 Collecting Duct
Carcinoma highly aggressive subtype of RCC that accounts for
lt1 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 21
The age range is 13ndash83 years (mean age 55 years)
typically appears as a gray-white infiltrative neoplasm with its epicenter in the pelvicalicealsystem
characterized by an infiltrative growth pattern at imaging
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
Collecting Duct Carcinoma
Power Doppler
sonogram of a
collecting duct
carcinoma shows a
solid hypovascular
medullary neoplasm
(arrows)
CECT
Contrast-enhanced
CT scan of a
collecting duct
carcinoma shows a
heterogeneously
enhancing left renal
mass (arrows) with
prominent
calcifications
(arrowheads)
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 21
appears as an infiltrative heterogeneous mass with a medullary epicenter
Manifests as an infiltrative heterogeneous medullaryneoplasm
Hemorrhage and necrosis contribute to tumor heterogeneity
Renal medullary carcinoma is typically associated with caliectasis
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
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)
Imaging of RCC
Ultrasonography
Intravenous Urography (IVU)
CT scanning more sensitive mass+renalhilum perinephric space and vena cava adrenals regional LN and adjacent organs
Renal Angiography
MRI to evaluate collecting system and IVC involvement
ULTRASONOGRAPHY
USG
Hyper echoic mostly in small tumors lt3
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
IVU of Right RCC
IVU
Diminished function (parenchymal
replacement hydronephrosis)
Absence of contrast excretion (renal vein
occlusion)
Necrotic part of tumour filled with
contrast media
NCCT
Unenhanced
CT scan shows
a 25-cm-
diameter soft-
tissue mass
deforming the
contour of the
right kidney
(arrow)
corticomedullary phase
Contrast-enhanced CT scan obtained during the corticomedullaryphase shows that the mass is hypoattenuatingcompared with the renal cortex and has peripheral enhancement (arrow) The cortex is brightly enhanced whereas the medulla is relatively unenhanced
nephrographic phase
Contrast-enhanced CT scan obtained during the nephrographicphase shows the hypervascularmass is well demarcated from the homogeneously enhancing renal parenchyma (arrow)
CT Scan of Left RCC
Heterogenous mass due to hemorrhagic necrosis
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
Cystic RCC
RCC invading renal vein
CT scan with 3D reconstruction
Neovascularity in Renal
Angiography
associated with RCC
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
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
Tumor Staging (Robson
System)
Tumor Staging (International
TNM Staging System)
Differential Diagnosis
bull Benign renal tumors
-Angiomyolipoma
bull Renal Pelvis Cancer
MRI
Axial T2-weighted MR image of a papillary RCC shows a round uniformly hypointensetumor (arrows) Note the multiple bilateral renal cysts (arrowheads)
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
Image Studies
Chromophobe RCC appears uniformly hyperechoic at ultrasonography
Despite their large size chromophobeRCCs demonstrate relatively homogeneous enhancement at CT and MR imaging
Chromophobe RCC may appear hypointense on T2-weighted MR images At catheter angiography chromophobeRCC is commonly hypovascular
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)
5 Collecting Duct
Carcinoma highly aggressive subtype of RCC that accounts for
lt1 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 21
The age range is 13ndash83 years (mean age 55 years)
typically appears as a gray-white infiltrative neoplasm with its epicenter in the pelvicalicealsystem
characterized by an infiltrative growth pattern at imaging
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
Collecting Duct Carcinoma
Power Doppler
sonogram of a
collecting duct
carcinoma shows a
solid hypovascular
medullary neoplasm
(arrows)
CECT
Contrast-enhanced
CT scan of a
collecting duct
carcinoma shows a
heterogeneously
enhancing left renal
mass (arrows) with
prominent
calcifications
(arrowheads)
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 21
appears as an infiltrative heterogeneous mass with a medullary epicenter
Manifests as an infiltrative heterogeneous medullaryneoplasm
Hemorrhage and necrosis contribute to tumor heterogeneity
Renal medullary carcinoma is typically associated with caliectasis
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
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)
Imaging of RCC
Ultrasonography
Intravenous Urography (IVU)
CT scanning more sensitive mass+renalhilum perinephric space and vena cava adrenals regional LN and adjacent organs
Renal Angiography
MRI to evaluate collecting system and IVC involvement
ULTRASONOGRAPHY
USG
Hyper echoic mostly in small tumors lt3
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
IVU of Right RCC
IVU
Diminished function (parenchymal
replacement hydronephrosis)
Absence of contrast excretion (renal vein
occlusion)
Necrotic part of tumour filled with
contrast media
NCCT
Unenhanced
CT scan shows
a 25-cm-
diameter soft-
tissue mass
deforming the
contour of the
right kidney
(arrow)
corticomedullary phase
Contrast-enhanced CT scan obtained during the corticomedullaryphase shows that the mass is hypoattenuatingcompared with the renal cortex and has peripheral enhancement (arrow) The cortex is brightly enhanced whereas the medulla is relatively unenhanced
nephrographic phase
Contrast-enhanced CT scan obtained during the nephrographicphase shows the hypervascularmass is well demarcated from the homogeneously enhancing renal parenchyma (arrow)
CT Scan of Left RCC
Heterogenous mass due to hemorrhagic necrosis
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
Cystic RCC
RCC invading renal vein
CT scan with 3D reconstruction
Neovascularity in Renal
Angiography
associated with RCC
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
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
Tumor Staging (Robson
System)
Tumor Staging (International
TNM Staging System)
Differential Diagnosis
bull Benign renal tumors
-Angiomyolipoma
bull Renal Pelvis Cancer
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
Image Studies
Chromophobe RCC appears uniformly hyperechoic at ultrasonography
Despite their large size chromophobeRCCs demonstrate relatively homogeneous enhancement at CT and MR imaging
Chromophobe RCC may appear hypointense on T2-weighted MR images At catheter angiography chromophobeRCC is commonly hypovascular
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)
5 Collecting Duct
Carcinoma highly aggressive subtype of RCC that accounts for
lt1 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 21
The age range is 13ndash83 years (mean age 55 years)
typically appears as a gray-white infiltrative neoplasm with its epicenter in the pelvicalicealsystem
characterized by an infiltrative growth pattern at imaging
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
Collecting Duct Carcinoma
Power Doppler
sonogram of a
collecting duct
carcinoma shows a
solid hypovascular
medullary neoplasm
(arrows)
CECT
Contrast-enhanced
CT scan of a
collecting duct
carcinoma shows a
heterogeneously
enhancing left renal
mass (arrows) with
prominent
calcifications
(arrowheads)
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 21
appears as an infiltrative heterogeneous mass with a medullary epicenter
Manifests as an infiltrative heterogeneous medullaryneoplasm
Hemorrhage and necrosis contribute to tumor heterogeneity
Renal medullary carcinoma is typically associated with caliectasis
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
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)
Imaging of RCC
Ultrasonography
Intravenous Urography (IVU)
CT scanning more sensitive mass+renalhilum perinephric space and vena cava adrenals regional LN and adjacent organs
Renal Angiography
MRI to evaluate collecting system and IVC involvement
ULTRASONOGRAPHY
USG
Hyper echoic mostly in small tumors lt3
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
IVU of Right RCC
IVU
Diminished function (parenchymal
replacement hydronephrosis)
Absence of contrast excretion (renal vein
occlusion)
Necrotic part of tumour filled with
contrast media
NCCT
Unenhanced
CT scan shows
a 25-cm-
diameter soft-
tissue mass
deforming the
contour of the
right kidney
(arrow)
corticomedullary phase
Contrast-enhanced CT scan obtained during the corticomedullaryphase shows that the mass is hypoattenuatingcompared with the renal cortex and has peripheral enhancement (arrow) The cortex is brightly enhanced whereas the medulla is relatively unenhanced
nephrographic phase
Contrast-enhanced CT scan obtained during the nephrographicphase shows the hypervascularmass is well demarcated from the homogeneously enhancing renal parenchyma (arrow)
CT Scan of Left RCC
Heterogenous mass due to hemorrhagic necrosis
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
Cystic RCC
RCC invading renal vein
CT scan with 3D reconstruction
Neovascularity in Renal
Angiography
associated with RCC
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
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
Tumor Staging (Robson
System)
Tumor Staging (International
TNM Staging System)
Differential Diagnosis
bull Benign renal tumors
-Angiomyolipoma
bull Renal Pelvis Cancer
Image Studies
Chromophobe RCC appears uniformly hyperechoic at ultrasonography
Despite their large size chromophobeRCCs demonstrate relatively homogeneous enhancement at CT and MR imaging
Chromophobe RCC may appear hypointense on T2-weighted MR images At catheter angiography chromophobeRCC is commonly hypovascular
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)
5 Collecting Duct
Carcinoma highly aggressive subtype of RCC that accounts for
lt1 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 21
The age range is 13ndash83 years (mean age 55 years)
typically appears as a gray-white infiltrative neoplasm with its epicenter in the pelvicalicealsystem
characterized by an infiltrative growth pattern at imaging
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
Collecting Duct Carcinoma
Power Doppler
sonogram of a
collecting duct
carcinoma shows a
solid hypovascular
medullary neoplasm
(arrows)
CECT
Contrast-enhanced
CT scan of a
collecting duct
carcinoma shows a
heterogeneously
enhancing left renal
mass (arrows) with
prominent
calcifications
(arrowheads)
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 21
appears as an infiltrative heterogeneous mass with a medullary epicenter
Manifests as an infiltrative heterogeneous medullaryneoplasm
Hemorrhage and necrosis contribute to tumor heterogeneity
Renal medullary carcinoma is typically associated with caliectasis
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
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)
Imaging of RCC
Ultrasonography
Intravenous Urography (IVU)
CT scanning more sensitive mass+renalhilum perinephric space and vena cava adrenals regional LN and adjacent organs
Renal Angiography
MRI to evaluate collecting system and IVC involvement
ULTRASONOGRAPHY
USG
Hyper echoic mostly in small tumors lt3
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
IVU of Right RCC
IVU
Diminished function (parenchymal
replacement hydronephrosis)
Absence of contrast excretion (renal vein
occlusion)
Necrotic part of tumour filled with
contrast media
NCCT
Unenhanced
CT scan shows
a 25-cm-
diameter soft-
tissue mass
deforming the
contour of the
right kidney
(arrow)
corticomedullary phase
Contrast-enhanced CT scan obtained during the corticomedullaryphase shows that the mass is hypoattenuatingcompared with the renal cortex and has peripheral enhancement (arrow) The cortex is brightly enhanced whereas the medulla is relatively unenhanced
nephrographic phase
Contrast-enhanced CT scan obtained during the nephrographicphase shows the hypervascularmass is well demarcated from the homogeneously enhancing renal parenchyma (arrow)
CT Scan of Left RCC
Heterogenous mass due to hemorrhagic necrosis
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
Cystic RCC
RCC invading renal vein
CT scan with 3D reconstruction
Neovascularity in Renal
Angiography
associated with RCC
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
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
Tumor Staging (Robson
System)
Tumor Staging (International
TNM Staging System)
Differential Diagnosis
bull Benign renal tumors
-Angiomyolipoma
bull Renal Pelvis Cancer
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)
5 Collecting Duct
Carcinoma highly aggressive subtype of RCC that accounts for
lt1 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 21
The age range is 13ndash83 years (mean age 55 years)
typically appears as a gray-white infiltrative neoplasm with its epicenter in the pelvicalicealsystem
characterized by an infiltrative growth pattern at imaging
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
Collecting Duct Carcinoma
Power Doppler
sonogram of a
collecting duct
carcinoma shows a
solid hypovascular
medullary neoplasm
(arrows)
CECT
Contrast-enhanced
CT scan of a
collecting duct
carcinoma shows a
heterogeneously
enhancing left renal
mass (arrows) with
prominent
calcifications
(arrowheads)
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 21
appears as an infiltrative heterogeneous mass with a medullary epicenter
Manifests as an infiltrative heterogeneous medullaryneoplasm
Hemorrhage and necrosis contribute to tumor heterogeneity
Renal medullary carcinoma is typically associated with caliectasis
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
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)
Imaging of RCC
Ultrasonography
Intravenous Urography (IVU)
CT scanning more sensitive mass+renalhilum perinephric space and vena cava adrenals regional LN and adjacent organs
Renal Angiography
MRI to evaluate collecting system and IVC involvement
ULTRASONOGRAPHY
USG
Hyper echoic mostly in small tumors lt3
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
IVU of Right RCC
IVU
Diminished function (parenchymal
replacement hydronephrosis)
Absence of contrast excretion (renal vein
occlusion)
Necrotic part of tumour filled with
contrast media
NCCT
Unenhanced
CT scan shows
a 25-cm-
diameter soft-
tissue mass
deforming the
contour of the
right kidney
(arrow)
corticomedullary phase
Contrast-enhanced CT scan obtained during the corticomedullaryphase shows that the mass is hypoattenuatingcompared with the renal cortex and has peripheral enhancement (arrow) The cortex is brightly enhanced whereas the medulla is relatively unenhanced
nephrographic phase
Contrast-enhanced CT scan obtained during the nephrographicphase shows the hypervascularmass is well demarcated from the homogeneously enhancing renal parenchyma (arrow)
CT Scan of Left RCC
Heterogenous mass due to hemorrhagic necrosis
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
Cystic RCC
RCC invading renal vein
CT scan with 3D reconstruction
Neovascularity in Renal
Angiography
associated with RCC
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
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
Tumor Staging (Robson
System)
Tumor Staging (International
TNM Staging System)
Differential Diagnosis
bull Benign renal tumors
-Angiomyolipoma
bull Renal Pelvis Cancer
5 Collecting Duct
Carcinoma highly aggressive subtype of RCC that accounts for
lt1 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 21
The age range is 13ndash83 years (mean age 55 years)
typically appears as a gray-white infiltrative neoplasm with its epicenter in the pelvicalicealsystem
characterized by an infiltrative growth pattern at imaging
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
Collecting Duct Carcinoma
Power Doppler
sonogram of a
collecting duct
carcinoma shows a
solid hypovascular
medullary neoplasm
(arrows)
CECT
Contrast-enhanced
CT scan of a
collecting duct
carcinoma shows a
heterogeneously
enhancing left renal
mass (arrows) with
prominent
calcifications
(arrowheads)
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 21
appears as an infiltrative heterogeneous mass with a medullary epicenter
Manifests as an infiltrative heterogeneous medullaryneoplasm
Hemorrhage and necrosis contribute to tumor heterogeneity
Renal medullary carcinoma is typically associated with caliectasis
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
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)
Imaging of RCC
Ultrasonography
Intravenous Urography (IVU)
CT scanning more sensitive mass+renalhilum perinephric space and vena cava adrenals regional LN and adjacent organs
Renal Angiography
MRI to evaluate collecting system and IVC involvement
ULTRASONOGRAPHY
USG
Hyper echoic mostly in small tumors lt3
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
IVU of Right RCC
IVU
Diminished function (parenchymal
replacement hydronephrosis)
Absence of contrast excretion (renal vein
occlusion)
Necrotic part of tumour filled with
contrast media
NCCT
Unenhanced
CT scan shows
a 25-cm-
diameter soft-
tissue mass
deforming the
contour of the
right kidney
(arrow)
corticomedullary phase
Contrast-enhanced CT scan obtained during the corticomedullaryphase shows that the mass is hypoattenuatingcompared with the renal cortex and has peripheral enhancement (arrow) The cortex is brightly enhanced whereas the medulla is relatively unenhanced
nephrographic phase
Contrast-enhanced CT scan obtained during the nephrographicphase shows the hypervascularmass is well demarcated from the homogeneously enhancing renal parenchyma (arrow)
CT Scan of Left RCC
Heterogenous mass due to hemorrhagic necrosis
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
Cystic RCC
RCC invading renal vein
CT scan with 3D reconstruction
Neovascularity in Renal
Angiography
associated with RCC
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
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
Tumor Staging (Robson
System)
Tumor Staging (International
TNM Staging System)
Differential Diagnosis
bull Benign renal tumors
-Angiomyolipoma
bull Renal Pelvis Cancer
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
Collecting Duct Carcinoma
Power Doppler
sonogram of a
collecting duct
carcinoma shows a
solid hypovascular
medullary neoplasm
(arrows)
CECT
Contrast-enhanced
CT scan of a
collecting duct
carcinoma shows a
heterogeneously
enhancing left renal
mass (arrows) with
prominent
calcifications
(arrowheads)
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 21
appears as an infiltrative heterogeneous mass with a medullary epicenter
Manifests as an infiltrative heterogeneous medullaryneoplasm
Hemorrhage and necrosis contribute to tumor heterogeneity
Renal medullary carcinoma is typically associated with caliectasis
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
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)
Imaging of RCC
Ultrasonography
Intravenous Urography (IVU)
CT scanning more sensitive mass+renalhilum perinephric space and vena cava adrenals regional LN and adjacent organs
Renal Angiography
MRI to evaluate collecting system and IVC involvement
ULTRASONOGRAPHY
USG
Hyper echoic mostly in small tumors lt3
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
IVU of Right RCC
IVU
Diminished function (parenchymal
replacement hydronephrosis)
Absence of contrast excretion (renal vein
occlusion)
Necrotic part of tumour filled with
contrast media
NCCT
Unenhanced
CT scan shows
a 25-cm-
diameter soft-
tissue mass
deforming the
contour of the
right kidney
(arrow)
corticomedullary phase
Contrast-enhanced CT scan obtained during the corticomedullaryphase shows that the mass is hypoattenuatingcompared with the renal cortex and has peripheral enhancement (arrow) The cortex is brightly enhanced whereas the medulla is relatively unenhanced
nephrographic phase
Contrast-enhanced CT scan obtained during the nephrographicphase shows the hypervascularmass is well demarcated from the homogeneously enhancing renal parenchyma (arrow)
CT Scan of Left RCC
Heterogenous mass due to hemorrhagic necrosis
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
Cystic RCC
RCC invading renal vein
CT scan with 3D reconstruction
Neovascularity in Renal
Angiography
associated with RCC
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
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
Tumor Staging (Robson
System)
Tumor Staging (International
TNM Staging System)
Differential Diagnosis
bull Benign renal tumors
-Angiomyolipoma
bull Renal Pelvis Cancer
Collecting Duct Carcinoma
Power Doppler
sonogram of a
collecting duct
carcinoma shows a
solid hypovascular
medullary neoplasm
(arrows)
CECT
Contrast-enhanced
CT scan of a
collecting duct
carcinoma shows a
heterogeneously
enhancing left renal
mass (arrows) with
prominent
calcifications
(arrowheads)
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 21
appears as an infiltrative heterogeneous mass with a medullary epicenter
Manifests as an infiltrative heterogeneous medullaryneoplasm
Hemorrhage and necrosis contribute to tumor heterogeneity
Renal medullary carcinoma is typically associated with caliectasis
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
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)
Imaging of RCC
Ultrasonography
Intravenous Urography (IVU)
CT scanning more sensitive mass+renalhilum perinephric space and vena cava adrenals regional LN and adjacent organs
Renal Angiography
MRI to evaluate collecting system and IVC involvement
ULTRASONOGRAPHY
USG
Hyper echoic mostly in small tumors lt3
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
IVU of Right RCC
IVU
Diminished function (parenchymal
replacement hydronephrosis)
Absence of contrast excretion (renal vein
occlusion)
Necrotic part of tumour filled with
contrast media
NCCT
Unenhanced
CT scan shows
a 25-cm-
diameter soft-
tissue mass
deforming the
contour of the
right kidney
(arrow)
corticomedullary phase
Contrast-enhanced CT scan obtained during the corticomedullaryphase shows that the mass is hypoattenuatingcompared with the renal cortex and has peripheral enhancement (arrow) The cortex is brightly enhanced whereas the medulla is relatively unenhanced
nephrographic phase
Contrast-enhanced CT scan obtained during the nephrographicphase shows the hypervascularmass is well demarcated from the homogeneously enhancing renal parenchyma (arrow)
CT Scan of Left RCC
Heterogenous mass due to hemorrhagic necrosis
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
Cystic RCC
RCC invading renal vein
CT scan with 3D reconstruction
Neovascularity in Renal
Angiography
associated with RCC
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
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
Tumor Staging (Robson
System)
Tumor Staging (International
TNM Staging System)
Differential Diagnosis
bull Benign renal tumors
-Angiomyolipoma
bull Renal Pelvis Cancer
CECT
Contrast-enhanced
CT scan of a
collecting duct
carcinoma shows a
heterogeneously
enhancing left renal
mass (arrows) with
prominent
calcifications
(arrowheads)
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 21
appears as an infiltrative heterogeneous mass with a medullary epicenter
Manifests as an infiltrative heterogeneous medullaryneoplasm
Hemorrhage and necrosis contribute to tumor heterogeneity
Renal medullary carcinoma is typically associated with caliectasis
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
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)
Imaging of RCC
Ultrasonography
Intravenous Urography (IVU)
CT scanning more sensitive mass+renalhilum perinephric space and vena cava adrenals regional LN and adjacent organs
Renal Angiography
MRI to evaluate collecting system and IVC involvement
ULTRASONOGRAPHY
USG
Hyper echoic mostly in small tumors lt3
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
IVU of Right RCC
IVU
Diminished function (parenchymal
replacement hydronephrosis)
Absence of contrast excretion (renal vein
occlusion)
Necrotic part of tumour filled with
contrast media
NCCT
Unenhanced
CT scan shows
a 25-cm-
diameter soft-
tissue mass
deforming the
contour of the
right kidney
(arrow)
corticomedullary phase
Contrast-enhanced CT scan obtained during the corticomedullaryphase shows that the mass is hypoattenuatingcompared with the renal cortex and has peripheral enhancement (arrow) The cortex is brightly enhanced whereas the medulla is relatively unenhanced
nephrographic phase
Contrast-enhanced CT scan obtained during the nephrographicphase shows the hypervascularmass is well demarcated from the homogeneously enhancing renal parenchyma (arrow)
CT Scan of Left RCC
Heterogenous mass due to hemorrhagic necrosis
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
Cystic RCC
RCC invading renal vein
CT scan with 3D reconstruction
Neovascularity in Renal
Angiography
associated with RCC
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
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
Tumor Staging (Robson
System)
Tumor Staging (International
TNM Staging System)
Differential Diagnosis
bull Benign renal tumors
-Angiomyolipoma
bull Renal Pelvis Cancer
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 21
appears as an infiltrative heterogeneous mass with a medullary epicenter
Manifests as an infiltrative heterogeneous medullaryneoplasm
Hemorrhage and necrosis contribute to tumor heterogeneity
Renal medullary carcinoma is typically associated with caliectasis
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
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)
Imaging of RCC
Ultrasonography
Intravenous Urography (IVU)
CT scanning more sensitive mass+renalhilum perinephric space and vena cava adrenals regional LN and adjacent organs
Renal Angiography
MRI to evaluate collecting system and IVC involvement
ULTRASONOGRAPHY
USG
Hyper echoic mostly in small tumors lt3
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
IVU of Right RCC
IVU
Diminished function (parenchymal
replacement hydronephrosis)
Absence of contrast excretion (renal vein
occlusion)
Necrotic part of tumour filled with
contrast media
NCCT
Unenhanced
CT scan shows
a 25-cm-
diameter soft-
tissue mass
deforming the
contour of the
right kidney
(arrow)
corticomedullary phase
Contrast-enhanced CT scan obtained during the corticomedullaryphase shows that the mass is hypoattenuatingcompared with the renal cortex and has peripheral enhancement (arrow) The cortex is brightly enhanced whereas the medulla is relatively unenhanced
nephrographic phase
Contrast-enhanced CT scan obtained during the nephrographicphase shows the hypervascularmass is well demarcated from the homogeneously enhancing renal parenchyma (arrow)
CT Scan of Left RCC
Heterogenous mass due to hemorrhagic necrosis
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
Cystic RCC
RCC invading renal vein
CT scan with 3D reconstruction
Neovascularity in Renal
Angiography
associated with RCC
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
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
Tumor Staging (Robson
System)
Tumor Staging (International
TNM Staging System)
Differential Diagnosis
bull Benign renal tumors
-Angiomyolipoma
bull Renal Pelvis Cancer
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
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)
Imaging of RCC
Ultrasonography
Intravenous Urography (IVU)
CT scanning more sensitive mass+renalhilum perinephric space and vena cava adrenals regional LN and adjacent organs
Renal Angiography
MRI to evaluate collecting system and IVC involvement
ULTRASONOGRAPHY
USG
Hyper echoic mostly in small tumors lt3
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
IVU of Right RCC
IVU
Diminished function (parenchymal
replacement hydronephrosis)
Absence of contrast excretion (renal vein
occlusion)
Necrotic part of tumour filled with
contrast media
NCCT
Unenhanced
CT scan shows
a 25-cm-
diameter soft-
tissue mass
deforming the
contour of the
right kidney
(arrow)
corticomedullary phase
Contrast-enhanced CT scan obtained during the corticomedullaryphase shows that the mass is hypoattenuatingcompared with the renal cortex and has peripheral enhancement (arrow) The cortex is brightly enhanced whereas the medulla is relatively unenhanced
nephrographic phase
Contrast-enhanced CT scan obtained during the nephrographicphase shows the hypervascularmass is well demarcated from the homogeneously enhancing renal parenchyma (arrow)
CT Scan of Left RCC
Heterogenous mass due to hemorrhagic necrosis
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
Cystic RCC
RCC invading renal vein
CT scan with 3D reconstruction
Neovascularity in Renal
Angiography
associated with RCC
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
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
Tumor Staging (Robson
System)
Tumor Staging (International
TNM Staging System)
Differential Diagnosis
bull Benign renal tumors
-Angiomyolipoma
bull Renal Pelvis Cancer
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)
Imaging of RCC
Ultrasonography
Intravenous Urography (IVU)
CT scanning more sensitive mass+renalhilum perinephric space and vena cava adrenals regional LN and adjacent organs
Renal Angiography
MRI to evaluate collecting system and IVC involvement
ULTRASONOGRAPHY
USG
Hyper echoic mostly in small tumors lt3
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
IVU of Right RCC
IVU
Diminished function (parenchymal
replacement hydronephrosis)
Absence of contrast excretion (renal vein
occlusion)
Necrotic part of tumour filled with
contrast media
NCCT
Unenhanced
CT scan shows
a 25-cm-
diameter soft-
tissue mass
deforming the
contour of the
right kidney
(arrow)
corticomedullary phase
Contrast-enhanced CT scan obtained during the corticomedullaryphase shows that the mass is hypoattenuatingcompared with the renal cortex and has peripheral enhancement (arrow) The cortex is brightly enhanced whereas the medulla is relatively unenhanced
nephrographic phase
Contrast-enhanced CT scan obtained during the nephrographicphase shows the hypervascularmass is well demarcated from the homogeneously enhancing renal parenchyma (arrow)
CT Scan of Left RCC
Heterogenous mass due to hemorrhagic necrosis
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
Cystic RCC
RCC invading renal vein
CT scan with 3D reconstruction
Neovascularity in Renal
Angiography
associated with RCC
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
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
Tumor Staging (Robson
System)
Tumor Staging (International
TNM Staging System)
Differential Diagnosis
bull Benign renal tumors
-Angiomyolipoma
bull Renal Pelvis Cancer
Imaging of RCC
Ultrasonography
Intravenous Urography (IVU)
CT scanning more sensitive mass+renalhilum perinephric space and vena cava adrenals regional LN and adjacent organs
Renal Angiography
MRI to evaluate collecting system and IVC involvement
ULTRASONOGRAPHY
USG
Hyper echoic mostly in small tumors lt3
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
IVU of Right RCC
IVU
Diminished function (parenchymal
replacement hydronephrosis)
Absence of contrast excretion (renal vein
occlusion)
Necrotic part of tumour filled with
contrast media
NCCT
Unenhanced
CT scan shows
a 25-cm-
diameter soft-
tissue mass
deforming the
contour of the
right kidney
(arrow)
corticomedullary phase
Contrast-enhanced CT scan obtained during the corticomedullaryphase shows that the mass is hypoattenuatingcompared with the renal cortex and has peripheral enhancement (arrow) The cortex is brightly enhanced whereas the medulla is relatively unenhanced
nephrographic phase
Contrast-enhanced CT scan obtained during the nephrographicphase shows the hypervascularmass is well demarcated from the homogeneously enhancing renal parenchyma (arrow)
CT Scan of Left RCC
Heterogenous mass due to hemorrhagic necrosis
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
Cystic RCC
RCC invading renal vein
CT scan with 3D reconstruction
Neovascularity in Renal
Angiography
associated with RCC
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
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
Tumor Staging (Robson
System)
Tumor Staging (International
TNM Staging System)
Differential Diagnosis
bull Benign renal tumors
-Angiomyolipoma
bull Renal Pelvis Cancer
ULTRASONOGRAPHY
USG
Hyper echoic mostly in small tumors lt3
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
IVU of Right RCC
IVU
Diminished function (parenchymal
replacement hydronephrosis)
Absence of contrast excretion (renal vein
occlusion)
Necrotic part of tumour filled with
contrast media
NCCT
Unenhanced
CT scan shows
a 25-cm-
diameter soft-
tissue mass
deforming the
contour of the
right kidney
(arrow)
corticomedullary phase
Contrast-enhanced CT scan obtained during the corticomedullaryphase shows that the mass is hypoattenuatingcompared with the renal cortex and has peripheral enhancement (arrow) The cortex is brightly enhanced whereas the medulla is relatively unenhanced
nephrographic phase
Contrast-enhanced CT scan obtained during the nephrographicphase shows the hypervascularmass is well demarcated from the homogeneously enhancing renal parenchyma (arrow)
CT Scan of Left RCC
Heterogenous mass due to hemorrhagic necrosis
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
Cystic RCC
RCC invading renal vein
CT scan with 3D reconstruction
Neovascularity in Renal
Angiography
associated with RCC
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
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
Tumor Staging (Robson
System)
Tumor Staging (International
TNM Staging System)
Differential Diagnosis
bull Benign renal tumors
-Angiomyolipoma
bull Renal Pelvis Cancer
USG
Hyper echoic mostly in small tumors lt3
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
IVU of Right RCC
IVU
Diminished function (parenchymal
replacement hydronephrosis)
Absence of contrast excretion (renal vein
occlusion)
Necrotic part of tumour filled with
contrast media
NCCT
Unenhanced
CT scan shows
a 25-cm-
diameter soft-
tissue mass
deforming the
contour of the
right kidney
(arrow)
corticomedullary phase
Contrast-enhanced CT scan obtained during the corticomedullaryphase shows that the mass is hypoattenuatingcompared with the renal cortex and has peripheral enhancement (arrow) The cortex is brightly enhanced whereas the medulla is relatively unenhanced
nephrographic phase
Contrast-enhanced CT scan obtained during the nephrographicphase shows the hypervascularmass is well demarcated from the homogeneously enhancing renal parenchyma (arrow)
CT Scan of Left RCC
Heterogenous mass due to hemorrhagic necrosis
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
Cystic RCC
RCC invading renal vein
CT scan with 3D reconstruction
Neovascularity in Renal
Angiography
associated with RCC
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
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
Tumor Staging (Robson
System)
Tumor Staging (International
TNM Staging System)
Differential Diagnosis
bull Benign renal tumors
-Angiomyolipoma
bull Renal Pelvis Cancer
IVU of Right RCC
IVU
Diminished function (parenchymal
replacement hydronephrosis)
Absence of contrast excretion (renal vein
occlusion)
Necrotic part of tumour filled with
contrast media
NCCT
Unenhanced
CT scan shows
a 25-cm-
diameter soft-
tissue mass
deforming the
contour of the
right kidney
(arrow)
corticomedullary phase
Contrast-enhanced CT scan obtained during the corticomedullaryphase shows that the mass is hypoattenuatingcompared with the renal cortex and has peripheral enhancement (arrow) The cortex is brightly enhanced whereas the medulla is relatively unenhanced
nephrographic phase
Contrast-enhanced CT scan obtained during the nephrographicphase shows the hypervascularmass is well demarcated from the homogeneously enhancing renal parenchyma (arrow)
CT Scan of Left RCC
Heterogenous mass due to hemorrhagic necrosis
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
Cystic RCC
RCC invading renal vein
CT scan with 3D reconstruction
Neovascularity in Renal
Angiography
associated with RCC
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
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
Tumor Staging (Robson
System)
Tumor Staging (International
TNM Staging System)
Differential Diagnosis
bull Benign renal tumors
-Angiomyolipoma
bull Renal Pelvis Cancer
IVU
Diminished function (parenchymal
replacement hydronephrosis)
Absence of contrast excretion (renal vein
occlusion)
Necrotic part of tumour filled with
contrast media
NCCT
Unenhanced
CT scan shows
a 25-cm-
diameter soft-
tissue mass
deforming the
contour of the
right kidney
(arrow)
corticomedullary phase
Contrast-enhanced CT scan obtained during the corticomedullaryphase shows that the mass is hypoattenuatingcompared with the renal cortex and has peripheral enhancement (arrow) The cortex is brightly enhanced whereas the medulla is relatively unenhanced
nephrographic phase
Contrast-enhanced CT scan obtained during the nephrographicphase shows the hypervascularmass is well demarcated from the homogeneously enhancing renal parenchyma (arrow)
CT Scan of Left RCC
Heterogenous mass due to hemorrhagic necrosis
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
Cystic RCC
RCC invading renal vein
CT scan with 3D reconstruction
Neovascularity in Renal
Angiography
associated with RCC
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
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
Tumor Staging (Robson
System)
Tumor Staging (International
TNM Staging System)
Differential Diagnosis
bull Benign renal tumors
-Angiomyolipoma
bull Renal Pelvis Cancer
NCCT
Unenhanced
CT scan shows
a 25-cm-
diameter soft-
tissue mass
deforming the
contour of the
right kidney
(arrow)
corticomedullary phase
Contrast-enhanced CT scan obtained during the corticomedullaryphase shows that the mass is hypoattenuatingcompared with the renal cortex and has peripheral enhancement (arrow) The cortex is brightly enhanced whereas the medulla is relatively unenhanced
nephrographic phase
Contrast-enhanced CT scan obtained during the nephrographicphase shows the hypervascularmass is well demarcated from the homogeneously enhancing renal parenchyma (arrow)
CT Scan of Left RCC
Heterogenous mass due to hemorrhagic necrosis
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
Cystic RCC
RCC invading renal vein
CT scan with 3D reconstruction
Neovascularity in Renal
Angiography
associated with RCC
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
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
Tumor Staging (Robson
System)
Tumor Staging (International
TNM Staging System)
Differential Diagnosis
bull Benign renal tumors
-Angiomyolipoma
bull Renal Pelvis Cancer
corticomedullary phase
Contrast-enhanced CT scan obtained during the corticomedullaryphase shows that the mass is hypoattenuatingcompared with the renal cortex and has peripheral enhancement (arrow) The cortex is brightly enhanced whereas the medulla is relatively unenhanced
nephrographic phase
Contrast-enhanced CT scan obtained during the nephrographicphase shows the hypervascularmass is well demarcated from the homogeneously enhancing renal parenchyma (arrow)
CT Scan of Left RCC
Heterogenous mass due to hemorrhagic necrosis
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
Cystic RCC
RCC invading renal vein
CT scan with 3D reconstruction
Neovascularity in Renal
Angiography
associated with RCC
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
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
Tumor Staging (Robson
System)
Tumor Staging (International
TNM Staging System)
Differential Diagnosis
bull Benign renal tumors
-Angiomyolipoma
bull Renal Pelvis Cancer
nephrographic phase
Contrast-enhanced CT scan obtained during the nephrographicphase shows the hypervascularmass is well demarcated from the homogeneously enhancing renal parenchyma (arrow)
CT Scan of Left RCC
Heterogenous mass due to hemorrhagic necrosis
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
Cystic RCC
RCC invading renal vein
CT scan with 3D reconstruction
Neovascularity in Renal
Angiography
associated with RCC
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
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
Tumor Staging (Robson
System)
Tumor Staging (International
TNM Staging System)
Differential Diagnosis
bull Benign renal tumors
-Angiomyolipoma
bull Renal Pelvis Cancer
CT Scan of Left RCC
Heterogenous mass due to hemorrhagic necrosis
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
Cystic RCC
RCC invading renal vein
CT scan with 3D reconstruction
Neovascularity in Renal
Angiography
associated with RCC
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
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
Tumor Staging (Robson
System)
Tumor Staging (International
TNM Staging System)
Differential Diagnosis
bull Benign renal tumors
-Angiomyolipoma
bull Renal Pelvis Cancer
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
Cystic RCC
RCC invading renal vein
CT scan with 3D reconstruction
Neovascularity in Renal
Angiography
associated with RCC
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
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
Tumor Staging (Robson
System)
Tumor Staging (International
TNM Staging System)
Differential Diagnosis
bull Benign renal tumors
-Angiomyolipoma
bull Renal Pelvis Cancer
Cystic RCC
RCC invading renal vein
CT scan with 3D reconstruction
Neovascularity in Renal
Angiography
associated with RCC
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
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
Tumor Staging (Robson
System)
Tumor Staging (International
TNM Staging System)
Differential Diagnosis
bull Benign renal tumors
-Angiomyolipoma
bull Renal Pelvis Cancer
RCC invading renal vein
CT scan with 3D reconstruction
Neovascularity in Renal
Angiography
associated with RCC
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
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
Tumor Staging (Robson
System)
Tumor Staging (International
TNM Staging System)
Differential Diagnosis
bull Benign renal tumors
-Angiomyolipoma
bull Renal Pelvis Cancer
CT scan with 3D reconstruction
Neovascularity in Renal
Angiography
associated with RCC
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
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
Tumor Staging (Robson
System)
Tumor Staging (International
TNM Staging System)
Differential Diagnosis
bull Benign renal tumors
-Angiomyolipoma
bull Renal Pelvis Cancer
Neovascularity in Renal
Angiography
associated with RCC
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
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
Tumor Staging (Robson
System)
Tumor Staging (International
TNM Staging System)
Differential Diagnosis
bull Benign renal tumors
-Angiomyolipoma
bull Renal Pelvis Cancer
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
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
Tumor Staging (Robson
System)
Tumor Staging (International
TNM Staging System)
Differential Diagnosis
bull Benign renal tumors
-Angiomyolipoma
bull Renal Pelvis Cancer
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
Tumor Staging (Robson
System)
Tumor Staging (International
TNM Staging System)
Differential Diagnosis
bull Benign renal tumors
-Angiomyolipoma
bull Renal Pelvis Cancer
Tumor Staging (Robson
System)
Tumor Staging (International
TNM Staging System)
Differential Diagnosis
bull Benign renal tumors
-Angiomyolipoma
bull Renal Pelvis Cancer
Tumor Staging (International
TNM Staging System)
Differential Diagnosis
bull Benign renal tumors
-Angiomyolipoma
bull Renal Pelvis Cancer
Differential Diagnosis
bull Benign renal tumors
-Angiomyolipoma
bull Renal Pelvis Cancer
