carcinoma de celulas renales y diferenciales en métodos diagnósticos de imagen

1. CARCINOMA DE
CÉLULAS RENALES (CCR)
DRA. MARIA ANTONIETA RAMOS
KAREN MEZA
Grupo 5.4
matrícula: 259943

2. RRC
malignant tumours
derived from the
renal epithelium
RRC
most common
malignant renal
tumour
variety of
radiographic
appearances

3. Epidemiology
Clinical
presentation
50-70 years
of age at
presentation
macroscopic
hematuria:
60%
male
predilection
of 2:1
flank pain:
40%
This triad is however only found in
10-15% of patients
palpable
flank mass:
30-40%

4. RISK FACTORS
cigarette
smoking
dialysis
obesity

5. PARANEOPLASIC SYNDROMES
Polycythaemi
a
Stauffer
syndrome
Hypercalc
aemia

7. Robson staging:
*stage I - limited to kidney
*stage II - involvement of perinephric fat but remains
limited to Gerota's fascia
*stage III
IIIa - renal vein involvement
IIIb - nodal involvement
IIIc - both IIIa and IIIb
*stage IV
IVa - direct invasion of adjacent organs / structures
IVb - distant metastases

8. CT
USED TO BOTH DIAGNOSE AND STAGE RENAL CELL CARCINOMAS
On non-contrast CT
the lesions appear
of soft tissue
attenuation
Approximately 30%
demonstrate some
calcification
In general small
lesions enhance
homogeneously
Larger lesions have
irregular
enhancement due
to areas of necrosis

9. MRI
IS ALSO ABLE TO SUGGEST THE LIKELY HISTOLOGY, ON THE GROUNDS
OF T2 DIFFERENCES
MRI
T1 - often heterogeneous due to
necrosis, haemorrhage and solid
components
T2 - appearances depend on
histology 6
clear cell RCC - hyper intense
papillary RCC - hypo intense

10. MRI
Tumour pseudocapsule
appears as an
hypointense rim
between the tumor and
the adjacent
parenchyma
Useful at imaging renal
vein and IVC tumour
thrombus
Presence of
enhancement in the
thrombus is able to
distinguish between
bland and tumour
thrombus

11. CASE REPORT
A 61 year old female patient presented to the Emergency Department
with feeling unwell, pyrexia, nausea and headache. She gave a history of
fever for the past three weeks with three episodes of rigors. She also gave
a history of recent loss of appetite and some weight loss. She had no
urinary problems.
On examination she looked pale. A mass was palpable in the right lower
quadrant and lumbar region. Liver and spleen were not palpable. There
were no signs of peritonitis.
Her pulse rate was 125/minute, BP 120/85 and temp 39.6 degree
Centigrade. She had blood tests in the Emergency Department which
revealed the following : Hb 12.0 g/dL, WCC 11.6 × 10(9)/litre and Platelets
237 × 10(9)/litre. Electrolytes and urea were as follows: Na 133 mmol/litre,
K+ 4.2 mmol/litre, Urea 5.1 mmol/litre and Creatinine 78 micromol/litre.
Chest X ray did not reveal any abnormality.
The patient had a CT which showed mass in the right Kidney.

16. DIFERENTIAL DIAGNOSIS
Renal adenoma
Renal oncocytoma
Angiomyolipoma

17. RENAL ONCOCYTOMA
5% of resected primary
adult epithelial renal
neoplasms
6th to 7th decades with
a peak incidence at 55
years of age
Up to three quarters of
patients are
asymptomatic
Large mass
Pseudocapsule, necrosis
is usually absent
sharp central stellate
scar
The only reliable feature
is evidence of metastasis
or aggressive infiltration
small tumours may
enhance
homogeneously, but
usually enhancement is
heterogenous and the
mass is larger
tumour thrombus is
absent

18. Angiography:
spoke wheel pattern, during
the capillary phase the tumour
demonstrates a homogenous
blush, lu acent avascular rim
may be seen due to the
compressed pseudocapsule

21. ANGIOMYOLIPOMA
composed of vascular,
smooth muscle and fat
elements
typically identified in
adults (mean age of
presentation 43 years)
F:M of 4:1
The remaining 20% are
seen in association with
phakomatoses, the vast
majority in the setting of
tuberous sclerosis
Retroperitoneal
haemorrhage;
Wunderlich syndrome
palpable mass, flank
pain, urinary tract
infections, haematuria,
renal failure,
hypertension
cornerstone of
diagnosis on all
modalities is the
demonstration of
macroscopic fat
in the setting of
haemorrhage, or when
lesions contain little fat,
appearances may be
difficult to distinguish
Most lesions involve the
cortex and
demonstrate
macroscopic fat (< 20HU)

22. A proportion of
angiomyolipomas are
fat-poor. This is
especially the case in
the setting of tuberous
sclerosis
Calcification is rare.
MRI: at saturated
techniques demonstrate
high signal on non-fat
saturated sequences,
and loss of signal
following fat saturation
india ink artifact at the
interface between fat
and non-fat
components

23. DSA - angiography
Angiomyolipomas are hypervascular
lesions demonstrating often characteristic
features:
micro or macro aneurysms
sharply marginated
dense early arterial network
late whorled appearance

25. RENAL ADENOMA
>3 cm in
patients of 5070 years of age
Male
predilection
CRR potential
It´s benign if it´s
>2cm
You can´t
diferentiate it
from RRC