Presentation
Dysuria, urinary urgency and increased urinary frequency. No lion pain, haematuria, or weight loss.
Patient Data
Well-defined exophytic isoechoic lesion at the lower pole of the right kidney, having no significant internal vascularity on the colour doppler ultrasound examination.
Findings: Well-defined enhancing subcapsular lesion at the lower pole of right kidney. It measures 2.7 x 2.4 cm and has an average density of 30, 97 & 71 Hounsfield units on plain, arterial & portovenous phases respectively. Renal vein and IVC are patent. No significant locoregional lymphadenopathy or evidence of distant metastases is seen. A few simple cysts are also seen in both kidneys. Two well-defined hypodense non-enhancing lesions are seen in the segment 8 & 6 of the liver, which are likely simple cysts. Small fat containing umbilical hernia. Impression: Enhancing lesion at the lower pole of the right kidney, suspicious for renal cell carcinoma (RCC).
Case Discussion
Procedure: Laparoscopic radical nephrectomy.
Gross description: Specimen submitted in a formalin container consists of a nephrectomy specimen with perinephric fat and 9 cm long ureter. A circumscribed, pale sub capsular tumour measuring 3.0 x 2.2 x 2.0 cm is seen at the lower pole of the right kidney. Adjacent to the main tumour, there is another, smaller discrete tumour nodule measuring 1.5 cm in maximum dimension, abutting the renal pelvis. The rest of the kidney is unremarkable.
Diagnosis: Chromophobe renal cell carcinoma. Histologic grade (Fuhrman nuclear grade): G2. Two discrete tumour nodules, 3.0 cm and 1.5 cm in maximum dimensions respectively (gross examination). Smaller tumour nodule mainly present in the fat of renal pelvis. Negative for perinephric tumour infiltration or lymphovascular invasion. No necrosis or sarcomatoid areas are identified. The ureter and hilar blood vessels are unremarkable and free of any tumour invasion. Pathologic staging; pT1a, pNx, pMx.
Immunohistochemical staining: The neoplastic cells are also strongly positive for colloidal iron stain and EMA (Monoclonal M. Anti-human-Clone E29, Monoclonal M. Antibody-Clone GP1.4). Very occasional cells are CK7 (Mono M. Anti-human-Clone OV-TL 12/30) positive. The cells are negative for Vimentin (Monoclonal M. Anti-Vimentin-Clone V9) and CK20 (Monoclonal M. Anti-human-Clone Ks20.8).
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