59 year old man with a 9 cm tan/brown renal mass.

MS96-8279 (1 slide) KIDNEY
Clinical: 59 year old man with a 9cm tan/brown renal mass.

DX: Renal cell carcinoma, granular cell type, nuclear grade 2 of 4
Confined to kidney, no lvs inv, margins free, tumor size 9.0 cms

Comment: The pure granular cell variant accounts for 7% of renal cell carcinomas. Cells with eosinophilic granular cytoplasm are often a component of higher grade clear cell rcca. Granular cell carcinomas tend to be o higher nuclear grade than clear cell renal cell ca. They behave and are treated identically stage for stage.
Grossly, the mitochondria-rich cells impart a brown color to the tumor.
(if these nuclei had more prominent nucleoli, it could easily pass for a grade 3 lesion)

83year old man with a 2 x 2 cm renal mass and...

MS95-1066 (1 slide) KIDNEY

Clinical: 83year old man with a 2 x 2 cm renal mass and a large paracaval lymph node.

DX: Renal cell carcinoma, sarcomatoid variant, grade 4 of f (Fuhrman)

Comment: The sarcomatoid variant is often high grade. It is unusual for a small renal cell carcinoma to metastasize, but this one was also found in his node.

61 year old white man with multiple nodules...

MS96-14954 (1 slide) KIDNEY

Clinical: 61 year old white man with multiple nodules in the right kidney.

DX: Renal cell carcinoma, clear cell type, nuclear grade 2 of 4 (Fuhrman)
Comment: Clear cell type represents approx. 70% of RCCs. They are multicentric in only 4% of cases. An alveolar pattern with nests of clear cells separated by thin, vascular septae is typical.

FUHRMAN GRADING SYSTEM

Characteristics
I Nuclei round, uniform, approximately 10 micro-meters; nucleoli inconspicuous or absent
II Nuclei slightly irregular, approximately 15 micro-meters; nucleoli evident
III Nuclei very irregular, approximately 20 micro-meters; nucleoli large and prominent
IV Nuclei bizarre and multilobated, 20 micro-meters or greater; nucleoli prominent; chromatin clumped
(Stage is most important, but grade also correlates with survival.)

49 year old woman with bilateral renal masses...

MS96-9955 (2slides)
KIDNEY

Clinical: 49 year old woman with bilateral renal masses who undergoes bilateral partial nephrectomies.



DX: #2 Papillary renal cell carcinoma (3.0cm)
#3 Renal papillary neoplasm of low malignant potential (2.0cm) see insert from report

Comment: The nomenclature of small renal cell neoplasms is not well sorted out at this time. Adenoma vs LMP vs small carcinoma is debated. Some call ALL renal cell neoplasms malignant because there are examples of small lesions that have metastasized in large series. Epstein prefers LMP for lesions smaller than 3.0 cms with no malignant features i.e., invasion, necrosis, hemorrhage or porminent atypia. Keep in mind that all stage 1 renal cell neoplasms are treated with surgery only, so calling a small benign appearing lesion a cortical adenoma or a small renal cell carcinoma won't affect treatment.

(insert)
Small lesions.
The diagnosis of renal cell lesions under 3 cm in diameter has been controversial. Most lesions under 3cm behave in a benign fasion. However, it is well documented that some lesions under 3cm will metastasize, although these cases may represent less than 5% of this group of lesions. We consider a non-oncocytic stage I, nuclear grade 1 or 2 lesion that is less than 3cm to be a renal cell lesion of low malignant potential, but would diagnose any tumor of higher stage or nuclear grade as carcinoma.
Review article Am. J. Clin. Path. 1995;103:624-635

54 year old woman with a left renal mass.

MS96-8408 (1 slide)
Clinical: 54 year old woman with a left renal mass.

DX:Renal cell carcinoma, predominantly clear cell, with focal sarcomatoid diff
Marked granulomatous inflammation
Comment: Clear cell, granular cell and sarcomatoid are different patterns of the "usual type" of renal cell carcinoma. Chromophobe carcinoma and papillary renal cell ca are ultrastructurally and cytogenetically distinct from the usual types of RCCa.
The sarcomatoid variant typically presents as a higher grade lesion, but probably behaves similarly stage for stage and grade for grade.
Remember to grade the nuclei of all renal cell carcinomas as the highest found, even if it's only the smallest focus.
The granulomatous inflammation is a curiosity. Stains for bugs were neg.