Evaluation and management of localized renal tumors





Contributors of Campbell-Walsh-Wein, 12th edition


William P. Parker, Matthew T. Gettman, Steven C. Campbell, Brian R. Lane, Phillip M. Pierorazio, Panagiotis Kallidonis, Evangelos Liatsikos, Thomas W. Jarrett, Surena F. Matin, Armine K. Smith, Ramaprasad Srinivasan, and W. Marston Linehan


Classification


Renal masses can be malignant, benign, or inflammatory ( Table 28.1 ), or they can be classified based on radiographic appearance (simple cystic, complex cystic, solid) ( Table 28.2 ).



Table 28.1

Renal Masses Classified by Pathologic Features

Modified from Srigley JR, Delahunt B, Eble, et al. The International Society of Urological Pathology (ISUP) Vancouver Classification of Renal Neoplasia. Am J Surg Pathol 2013;37(10):1469-1489.



















MALIGNANT BENIGN
Renal Cell Carcinoma (RCC) Nephroblastic Tumors a Cystic Lesions


  • •

    Clear cell RCC


  • •

    Multilocular cystic clear cell renal cell neoplasm of low malignant potential


  • •

    Papillary RCC


  • •

    Chromophobe RCC


  • •

    Hybrid oncocytic chromophobe tumor


  • •

    Carcinoma of the collecting ducts of Bellini


  • •

    Renal medullary carcinoma


  • •

    MiT family translocation RCC a


  • •

    Xp11 translocation RCC


  • •

    t(6;11) RCC


  • •

    Mucinous tubular and spindle cell carcinoma


  • •

    Tubulocystic RCC


  • •

    Acquired cystic disease–associated RCC


  • •

    Clear cell (tubulo) papillary RCC


  • •

    Hereditary leiomyomatosis RCC syndrome–associated RCC


  • •

    RCC, unclassified



  • •

    Nephrogenic rests


  • •

    Nephroblastoma (Wilms tumor)


  • •

    Cystic partially differentiated nephroblastoma


Carcinoma Associated with Neuroblastoma


  • Neuroendocrine Tumors



    • •

      Carcinoid (low-grade neuroendocrine tumor)


    • •

      Neuroendocrine carcinoma (high-grade neuroendocrine tumor)


    • •

      Primitive neuroectodermal tumor


    • •

      Neuroblastoma


    • •

      Pheochromocytoma




  • Hematopoietic and Lymphoid Tumors



    • •

      Lymphoma


    • •

      Leukemia


    • •

      Plasmacytoma




  • Germ Cell Tumors



    • •

      Teratoma


    • •

      Choriocarcinoma




  • •

    Simple cyst


  • •

    Hemorrhagic cyst





  • Solid Lesions



    • •

      Angiomyolipoma


    • •

      Oncocytoma


    • •

      Papillary adenoma (renal adenoma)


    • •

      Metanephric tumors (adenoma, adenofibroma, stromal tumor)


    • •

      Congenital mesoblastic nephroma a


    • •

      Cystic nephroma/mixed epithelial stromal tumor


    • •

      Reninoma (juxtaglomerular cell tumor)


    • •

      Renomedullary interstitial tumor


    • •

      Leiomyoma


    • •

      Fibroma


    • •

      Hemangioma


    • •

      Lymphangioma


    • •

      Schwannoma


    • •

      Solitary fibrous tumor


Urothelium-Based Cancers


  • • Urothelial carcinoma



  • • Squamous cell carcinoma



  • • Adenocarcinoma


Sarcomas

  • •

    Leiomyosarcoma


  • •

    Liposarcoma


  • •

    Other sarcomas

Metastasis Invasion by Adjacent Neoplasm Vascular Lesions

  • •

    Renal artery aneurysm


  • •

    Arteriovenous malformation


Pseudotumor Inflammatory

  • •

    Abscess


  • •

    Focal pyelonephritis


  • •

    Xanthogranulomatous pyelonephritis


  • •

    Infected renal cyst


  • •

    Tuberculosis


  • •

    Rheumatic granuloma


a More common in children and young adults.



Table 28.2

Radiologic and Pathologic Correlates for Renal Masses

Modified from Simmons MN, Herts BR, Campbell SC. Image based approaches to the diagnosis of renal masses [lesson 39]. AUA Update Series 2007;26:382-391.



























Simple Cystic Strongly Enhancing Mass Infiltrative Mass



  • Benign cyst



  • Parapelvic cyst



  • Hydronephrosis



  • Caliceal diverticulum




  • Clear cell RCC



  • Angiomyolipoma



  • Oncocytoma



  • Papillary RCC (occasionally)



  • Chromophobe RCC (occasionally)




  • Lymphoma



  • High-grade urothelial carcinoma



  • Sarcomatoid differentiation



  • Collecting duct carcinoma



  • Renal medullary carcinoma



  • Xanthogranulomatous pyelonephritis



  • Metastasis (occasionally)

Complex Cystic Moderately Enhancing Solid Mass Calcified Mass



  • Cystic RCC



  • Hemorrhagic cyst



  • Hyperdense cyst



  • Benign complex cyst



  • Cystic nephroma



  • Mixed epithelial-stromal tumor



  • Cystic Wilms tumor



  • Infected cyst or abscess



  • Hydrocalix



  • Arteriovenous malformation



  • Renal artery aneurysm




  • Papillary RCC



  • Chromophobe RCC



  • Clear cell RCC (occasionally)



  • Oncocytoma



  • Fat-poor angiomyolipoma



  • Adenoma/metanephric adenoma



  • Unifocal lymphoma



  • Sarcoma



  • Lobar nephronia



  • Pseudotumor



  • Infarct



  • Metastasis




  • RCC



  • Urothelial carcinoma



  • Benign complex cyst



  • Xanthogranulomatous pyelonephritis



  • Renal artery aneurysm



  • Concomitant nephrolithiasis

Fat-Containing Mass Multifocal/Bilateral Masses



  • Angiomyolipoma



  • Liposarcoma



  • Lipoma




  • Familial RCC



  • Metastases



  • Sporadic, multifocal RCC (particularly papillary RCC or clear cell RCC)



  • Angiomyolipomas (tuberous sclerosis)



  • Lymphoma



  • Cystic tumors (autosomal dominant polycystic kidney disease)


RCC, Renal cell carcinoma.


Benign renal tumors


Renal cysts


Epidemiology, etiology, and pathophysiology.


Renal cyst disease is the most common benign renal tumor. Up to 10% of the population may harbor a renal cyst, with putative risk factors being age, male gender, hypertension, and worsening renal function.


Evaluation.


To aid in the evaluation of renal cyst disease, the Bosniak classification ( Table 28.3 ) is a commonly used method to characterize cysts and their risk of malignancy.



Table 28.3

Classification of Complex Renal Cysts










































BOSNIAK CLASSIFICATION RADIOGRAPHIC FEATURES RISK OF MALIGNANCY MANAGEMENT
I


  • Water density



  • Homogeneous, hairline thin wall



  • No septa



  • No calcification



  • No enhancement

None Surveillance not necessary
II


  • Few hairline septa in which “perceived” enhancement may be present



  • Fine calcification or short segment of slightly thickened calcification in wall or septa



  • No unequivocal enhancement

Minimal Surveillance not necessary
Hyperdense lesion: ≤3 cm, well marginated, with no unequivocal enhancement Minimal Periodic surveillance
IIF


  • Multiple hairline thin septa



  • Minimal smooth wall thickening



  • “Perceived” enhancement of wall or septae may be present



  • Calcification may be thick or nodular but must be without enhancement



  • Generally well marginated



  • No unequivocal enhancement

3%–5% Periodic surveillance
Hyperdense lesion: >3 cm or totally intrarenal with no enhancement 5%–10% Periodic surveillance
III “Indeterminate,” thickened irregular or smooth walls or septa in which measurable enhancement is present 50% Surgical excision a
IV Clearly malignant lesions that can have all the criteria of category III but also contain enhancing soft-tissue components 75%–90% Surgical excision a

a Surgical excision should be considered if the patient is in good health. Active surveillance is an option for select patients. Thermal ablation is probably best avoided for cystic lesions because of concern about tumor spillage.



Management options.


For most simple renal cysts, no additional follow-up is required, with the maximal intervention of serial imaging recommended for Bosniak IIF lesions.


Surgical resection or ablation is recommended for Bosniak III/IV lesions.


Management can include aspiration, cyst decortication, cyst resection, sclerotherapy, arterial embolization, and even nephrectomy depending on the cause and symptom. Acquired cystic kidney disease (ACKD) is associated with a significant increase in malignancy risk and should be followed closely.


Oncocytoma


Epidemiology, etiology, and pathophysiology.


Up to 25% of renal masses smaller than 3 cm represent oncocytomas. The most common benign enhancing renal mass. Associated with Birt-Hogg-Dube syndrome: pulmonary cysts, spontaneous pneumothoraces, and fibrofolliculomas.


Oncocytoma can be associated with perirenal fat invasion and renal vein invasion, findings that carry prognostic significance in renal cell carcinoma (RCC) but do not in oncocytoma and should not be interpreted as an aggressive pathology


Evaluation.


Hypervascularity and a central scar on axial imaging, but these alone are insufficient for a definitive diagnosis. Histologically similar to chromophobe RCC, and immunohistochemical staining may be required to distinguish the two.


Management.


When diagnosed by renal mass biopsy, the role of active surveillance (AS) has been explored with favorable results


Angiomyolipoma


Diagnosis.


Contrary to other benign renal masses, the diagnosis of angiomyolipoma (AML) can be made on imaging. The presence of macroscopic fat on computed tomography (CT) or magnetic resonance imaging (MRI) is diagnostic of AML. On CT the presence of intralesional fat (−15 to −20 Hounsfield units [HU]) on nonenhanced series is diagnostic. Tuberous sclerosis is associated with the development of multifocal and bilateral renal AML and is associated with activation of the mTOR pathway.


Management.


The management of patients with an AML should be individualized on the basis of sporadic versus syndromic AML, the presence of symptoms, the perceived risk of hemorrhage ( Fig. 28.1 ), and with the goal of preserving renal function. The treatment of choice in patients with acute hemorrhage is selective renal angioembolization. Everolimus is indicated for the management of larger, multifocal AMLs in patients with tuberous sclerosis complex (TSC) and lymphangioleiomyomatosis (LAM).




Fig. 28.1


Proposed updated management algorithm for renal angiomyolipoma (AML) by Flum et al. Algorithm represents suggested options. CT, Computed tomography; MRI, magnetic resonance imaging; NSS, nephron sparing surgery; RFA , radiofrequency ablation; TSC, tuberous sclerosis complex.

(From Flum AS, Hamoui N, Said MA, et al. Update on the diagnosis and management of renal angiomyolipoma. J Urol 2016;195[4 Pt 1]:834-846.)


Other benign tumors


Other tumors include papillary adenoma, metanephric adenoma, cystic nephroma/mixed epithelial-stromal tumors, leiomyoma, and other rare tumors.


Malignant renal tumors


Renal cell carcinoma


Incidence




  • •

    Up to 2%–3% of all adult malignant neoplasms, with a male-to-female predominance of 1.9 to 1. RCC typically is diagnosed between 55 and 75 years of age.


  • •

    The most lethal of the common urologic cancers.


  • •

    Usually sporadic; only 4%–6% are believed to be familial.


  • •

    The incidence has increased since the 1970s by an average of 3% per year, with more prevalent use of ultrasonography and CT for other nonspecific abdominal complaints, which increases the relative risk by 1.4 to 2.5-fold compared with control participants. Hypertension and obesity are also associated with increased prevalence of RCC.



Etiology.


The strongest risk factor for RCC is tobacco exposure, which provides a relative risk of 1.4 to 2.5 compared with control participants.


Obesity provides a relative risk of 1.07 for each additional unit of body mass index.


Hypertension appears to be the third major causative factor for RCC. Approximately 4%–6% of RCC is familial in origin.


Familial renal cell carcinoma and molecular genetics.


The distinct nature of the various subtypes of RCC and advances in molecular genetics have contributed to a major revision in the histologic classification of this malignancy ( Tables 28.4 and 28.5 ).



Table 28.4

Familial Renal Cell Carcinoma Subtypes

Modified from Schmidt LS, Linehan WM. Genetic predisposition to kidney cancer. Semin Oncol 2016;43:566-574.
































































SYNDROME PREDISPOSING GENE (CHROMOSOME) RENAL TUMOR HISTOLOGY AND OTHER MAJOR CLINICAL MANIFESTATIONS RECOMMENDED MANAGEMENT FOR RENAL TUMORS POTENTIAL THERAPEUTIC TARGETS
von Hippel-Lindau disease (VHL) VHL (3p25)


  • Clear cell RCC, often multifocal



  • Retinal angiomas



  • Central nervous system hemangioblastomas



  • Pheochromocytoma



  • Other tumors




  • Active surveillance <3 cm



  • Surgical excision ≥3 cm, preference for nephron-sparing approaches

HIF-VEGF pathway
Hereditary papillary renal carcinoma (HPRC) MET (7q31) Multiple, bilateral type 1 papillary RCC


  • Active surveillance <3 cm



  • Surgical excision ≥3 cm, preference for nephron-sparing approaches

MET kinase
Hereditary leiomyomatosis and renal cell carcinoma (HLRCC) Fumarate hydratase (FH) (1q42-43)


  • Type 2 papillary RCC most common



  • Collecting duct carcinoma



  • Leiomyomas of skin or uterus



  • Uterine leiomyosarcomas



  • Low-grade variants of RCC also seen in children

Surgical excision, preference for PN but only when wide margins can be achieved HIF-VEGF pathway; antioxidant response pathway; reductive carboxylation pathway
Succinate dehydrogenase-deficient RCC (SDH-RCC)


  • SDHA



  • SDHB (1p36.13), SDHC (1q23.3), SDHD (11q23.1), SHDAF2




  • SDH-associated RCC (chromophobe, clear cell, type 2 papillary RCC; or oncocytoma), variable aggressiveness



  • Paragangliomas (benign and malignant)



  • Papillary thyroid carcinoma

Surgical excision, preference for PN but only when wide margins can be achieved HIF-VEGF pathway; reductive carboxylation pathway
Birt-Hogg-Dube syndrome (BHD) Folliculin (17p11.2)


  • Multiple chromophobe RCC, hybrid oncocytic tumors, oncocytomas



  • Clear cell RCC (occasionally)



  • Papillary RCC (occasionally)



  • Facial fibrofolliculomas



  • Lung cysts



  • Spontaneous pneumothorax




  • Active surveillance <3 cm



  • Surgical excision ≥3 cm, preference for nephron-sparing approaches

mTOR pathway
PTEN hamartoma tumor syndrome (Cowden syndrome) PTEN (10q23)


  • Papillary RCC or other histology



  • Breast tumors (malignant and benign)



  • Epithelial thyroid carcinoma




  • Active surveillance <3 cm



  • Surgical excision ≥3 cm, preference for nephron-sparing approaches

Tuberous sclerosis complex (TSC)


  • TSC1 (9q34) or



  • TSC2 (16p13.3)




  • Multiple renal angiomyolipomas



  • Clear cell RCC (2%–3% incidence)



  • Renal cysts/polycystic kidney disease



  • Cardiac rhabdomyomas



  • Cutaneous angiofibromas



  • Pulmonary lymphangiomyomatosis



  • Neuropsychiatric disorders, including autism spectrum disorder and cognitive disability




  • AML: surveillance for <3 cm, everolimus for 3–5 cm, consideration for embolization or excision for ≥5 cm, preference for nephron-sparing approaches



  • RCC: surgical excision ≥3 cm, preference for nephron-sparing approaches

mTOR pathway
BAP1 tumor predisposition syndrome BAP1 (3p21.2) Clear cell RCC; can be high grade Surgical excision, preference for nephron-sparing approaches To be determined
MiTF-associated cancer syndrome MiTF (3p14.1–p12.3) Not defined To be determined To be determined

AML, Angiomyolipoma; CNS, central nervous system; MiTF, microphthalmia-associated transcription factor; PN, partial nephrectomy; PTEN, pentaerythritol tetranitrate; RCC, renal cell carcinoma.


Table 28.5

Manifestations of von Hippel-Lindau Disease

Modified from Nielsen SM, Rhodes L, Blanco I, et al. von Hippel-Lindau disease: genetics and role of genetic counseling in a multiple neoplasia syndrome. J Clin Oncol 2016;34(18):2172-2181.
































































TUMOR AGE OF ONSET, MEAN (RANGE), YEARS INCIDENCE (%)
Central Nervous System



  • Retinal hemangioblastoma

25 (1–68) 25–60



  • Endolymphatic sac tumor

22 (12–50) 10–15



  • Craniospinal hemangioblastoma (overall)

30 (9–70) 60–80






    • Cerebellum


33 (9–78) 44–72






    • Brainstem


32 (12–46) 10–25






    • Spinal cord


33 (11–66) 13–50
Visceral



  • Renal cell carcinoma

39 (13–70) 25–75



  • Renal cysts

39 (13–70) 20–60



  • Pheochromocytoma

27 (5–58) 10–25



  • Pancreatic neuroendocrine tumors (benign and malignant)

36 (5–70) 11–17



  • Pancreatic cysts

36 (5–70) 45–75



  • Epididymal cystadenoma

Unknown 25–60



  • Broad ligament cystadenoma

Unknown (16–46) Unknown


Pathology.


All RCCs are, by definition, adenocarcinomas, derived from renal tubular epithelial cells ( Table 28.6 ).



Table 28.6

Pathologic Subtypes of Renal Cell Carcinoma

Modified from Eble JN, Sauter G, Epstein JI, et al. WHO classification of tumours: pathology and genetics of tumours of the urinary system and male genital organs. Lyon, France: IARC Press, 2004; Srigley JR, Delahunt B, Eble J N, et al. The International Society of Urological Pathology (ISUP) Vancouver classification of renal neoplasia. Am J Surg Pathol 2014;37(10):1469-1489; Moch H, Cubilla AL, Humphrey PA, et al. The 2016 WHO classification of tumours of the urinary system and male genital organs—part A: renal, penile, and testicular tumours. Eur Urol 2016;70(1):93-105.














































































































HISTOLOGY a FAMILIAL FORM AND GENETIC FACTORS GROSS CHARACTERISTICS MICROSCOPIC PATHOLOGIC CHARACTERISTICS OTHER CHARACTERISTICS
Common Subtypes
Clear cell RCC (70%–80%)


  • von Hippel-Lindau (VHL) disease



  • VHL gene (3p25) mutation or hypermethylation



  • Chromosome 3p deletions



  • Loss of chromosome 8p, 9p, 14q; gain of chromosome 5q




  • Typically well-circumscribed, lobulated, golden yellow tumor but can be infiltrative



  • Necrosis, hemorrhage, and cystic degeneration common



  • Venous involvement also common




  • Hypervascular tumor



  • Nests or sheets of clear cells with delicate vascular network



  • IHC b : LMWCKs c , vimentin, EMA, CA-IX




  • Originates from proximal tubule



  • Aggressive behavior more common



  • Often responds to targeted molecular therapy and immunotherapy

Papillary RCC Type 1 (5%–10%)


  • HPRC



  • Altered MET proto-oncogene status present in 81% of sporadic cases



  • Trisomy of chromosome 7 and 17




  • Fleshy tumor with fibrous pseudocapsule



  • Necrosis and hemorrhage are common




  • Hypovascular tumor



  • Papillary structures with single layer of cells around fibrovascular cores



  • Basophilic cells with low-grade nuclei



  • IHC b : LMWCKs c , CK7 (type 1 > type 2), AMACR




  • Originates from proximal tubule



  • Good prognosis



  • Often multicentric



  • Common in ARCD

Papillary RCC type 2 (5%–10%)


  • HLRCC



  • Fumarate hydratase (FH) gene (1q42-43) mutation in HLRCC




  • Fleshy tumor with fibrous pseudocapsule



  • Necrosis and hemorrhage are common




  • Hypovascular tumor



  • Papillary structures with single layer of cells around fibrovascular cores



  • Eosinophilic cells with high-grade nuclei



  • IHC b : LMWCKs c , AMACR




  • Originates from proximal tubule



  • Worse prognosis then type 1 papillary RCC; similar or worse prognosis when compared with clear cell RCC

Chromophobe RCC (3%–5%)


  • Birt-Hogg-Dube (BHD) syndrome



  • Folliculin ( FLCN ) gene mutation (17p11)



  • Loss of multiple chromosomes (1, 2, 6, 10, 13, 17, 21, Y)



  • TPS3 and PTEN mutations




  • Well-circumscribed, homogeneous



  • Tan or light brown cut surface




  • “Plant cells” with pale cytoplasm, perinuclear clearing or “halo,” nuclear “raisins,” and prominent cell borders (classic subtype)



  • Positive Hale’s colloidal iron staining



  • IHC b : diffuse CK7



  • Eosinophilic subtype has dense pink cytoplasm and mitochondrial gene mutations




  • Originates from intercalated cells of collecting duct



  • Generally good prognosis, although sarcomatoid variant associated with poor prognosis

Clear cell papillary RCC (∼5%) VHL disease Well-circumscribed, well-developed capsule


  • Low-grade clear epithelial cells organized in linear papillae and tubules



  • IHC b : diffuse CK7; cuplike CA-IX distribution




  • Arise in ESRD and VHL



  • Good prognosis, indolent tumor behavior

Unclassified RCC (1%–3%) Unknown Varied Varied


  • Origin not defined



  • Generally poor prognosis

Rare Subtypes (Each Represents <1%)
Carcinoma of the collecting ducts of Bellini (collecting duct carcinoma)


  • Unknown



  • Multiple chromosomal losses




  • Firm, centrally located tumor with infiltrative borders



  • Light gray to tan-white




  • Complex, highly infiltrative cords within inflamed (desmoplastic) stroma



  • High-grade nuclei, mitoses




  • Originates from collecting duct



  • Poor prognosis



  • May respond to cytotoxic chemotherapy

Renal medullary carcinoma Associated with sickle cell trait


  • Infiltrative, gray-white



  • Extensive hemorrhage and necrosis




  • Poorly differentiated cells with lacelike appearance



  • Inflammatory infiltrate




  • Originates from collecting duct



  • Dismal prognosis

Hereditary leiomyomatosis and renal cell carcinoma (HLRCC)–associated RCC


  • HLRCC



  • Fumarate hydratase (FH) gene (1q42-43) mutation




  • Fleshy tumor with fibrous pseudocapsule



  • Necrosis and hemorrhage are common




  • Hypovascular tumor



  • Papillary structures with single layer of cells around fibrovascular cores



  • Eosinophilic cells with high-grade nuclei



  • IHC b : LMWCKs c , AMACR




  • Tendency to metastasize early with extremely poor prognosis



  • Low-grade variant recently described in children

Succinate dehydrogenase-deficient renal carcinoma


  • SDH-RCC



  • SDHA, SDHB (1p36.13), SDHC (1q23.3), SDHD (11q23.1), SHDAF2

Solitary lesion


  • Vacuolated eosinophilic or clear cells



  • Shares features with chromophobe RCC, oncocytoma, clear cell RCC, type 2 papillary RCC



  • IHC b : loss of SDHB




  • Presents in young adults, most often in those with a germline mutation in an SDH gene



  • HIF-VEGF pathway; reductive carboxylation pathway



  • High- and low-grade variants have been described

MiT family translocation RCC (includes Xp11 translocation RCC and t(6;11) RCC) Various mutations involving chromosome Xp11.2 resulting in TFE3 gene fusion Well-circumscribed, tan-yellow tumor


  • Variable; often clear cells with papillary architecture



  • IHC b : nuclear TFE3




  • Occurs in children and young adults; accounts for 40% of pediatric RCC



  • t(X;17) presents with advanced stage and often follows indolent course



  • t(X;1) can recur with late lymph node metastases

Acquired cystic disease-associated RCC


  • VHL gene alterations



  • Chromosome 3p deletion

Cystic degeneration


  • Cribriform, microcystic or sieve-like architecture



  • Cysts lined with single layer of clear cells



  • IHC b : absent CK7




  • Occurs in patients with ESRD and acquired cystic kidney disease



  • Excellent prognosis

Multilocular cystic clear cell renal neoplasm of low malignant potential Identical to clear cell RCC Well-circumscribed mass of small and large cysts


  • Cysts lined by single layer of low grade clear cells



  • No expansive nodules of tumor cells

Almost uniformly benign clinical behavior
Tubulocystic RCC Unknown Multiple small to medium renal cysts with spongy appearance


  • Enlarged nucleoli (grade 3)



  • Eosinophilic and oncocytoma-like cytoplasm

Favorable prognosis
Mucinous tubular and spindle cell carcinoma Unknown Well-circumscribed, tan-white-pink tumors centered in medulla Mixture of tubules and spindle-shaped epithelial cells; mucin background Favorable prognosis
Hybrid oncocytic chromophobe tumor


  • Birt-Hogg-Dube (BHD) syndrome



  • Folliculin (FLCN) gene mutation (17p11)




  • Well-circumscribed, homogeneous appearance



  • Tan or light brown cut surface

Shares features with chromophobe RCC and oncocytoma; often coexists with these tumors in BHD patients Generally good prognosis

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Nov 9, 2024 | Posted by in UROLOGY | Comments Off on Evaluation and management of localized renal tumors

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