1235

Case
:
.::..:...

Report
H

Cystic Renal Cell Carcinoma: Benign Hyperdense Cyst

David S. Hartman,1 John D. Baluch5 Ellsworth Weatherby 111,2.3William

CT Findings
B. Laskin,4 Jeffrey M. Brody,2

Simulating
William Gorse,2

a
and

Renal masses

with attenuation

values

ranging

from 40 H

to 90 H on unenhanced CT scans are considered hyperdense lesions. The differential diagnosis for such hyperdense masses includes benign entities such as a hyperdense cyst and primary and secondary malignant neoplasms [1 -3]. CT criteria have been proposed to distinguish benign hyperdense cysts from the other hyperdense lesions [1 4]. We report a case of cystic renal cell carcinoma that fulfilled all of the CT criteria for a benign hyperdense cyst.
,

A subsequent sonographic examination was cystic (bright back-wall enhancement) echoes within it. During surgical exploration,

showed that the mass but had a few low-level

the surface of the cystic mass was found to be more vascular than it would be in a typical simple cyst, suggestive of malignancy, and therefore a nephrectomy was performed. On gross examination, the cystic mass was found to be filled with straw-colored fluid. The wall was smooth without nodulanty or focal thickening. On microscopic examination, the cystic mass was seen to be surrounded by a uniformly thickened fibrous wall that was
partially lined by a single layer of cuboidal cells with uniform small

nuclei

and scanty

clear

cytoplasm

(Fig.

1C).

Microscopic

papillary

Case Report
A 70-year-old man with newly diagnosed stage B prostatic carcinoma had abdominal CT as part of his evaluation. Results of routine
laboratory studies, including urinalysis, were all within normal limits.

excrescences

composed

of branching

fibrovascular

fronds lined by a

single layer of neoplastic clear cells were found in several foci (FIg. 1 D). Solid aggregates, nests, or tubular arrangements of tumor were not present, nor was any evidence of parenchyrnal or vascular invasion found. Degenerative features such as hemorrhage, hernosiderin deposition, or foamy histiocytes were not present. The renal final

Contrast-enhanced

CT scans

showed scans
The

a 2.5-cm through
was

mass

in the lower

pole of the left kidney.

performed
without contrast

Dedicated
3-mm

renal CT (Figs. 1A and 1B) was

the mass with and
smooth, round, mass

capsule was intact and no vascular

pathologic diagnosis

invasion had occurred.

cystic

The

next and included

enhancement.

was stage I unilocular

renal cell carcinoma.

sharply marginated, homogeneous, and measured 44.5 H and 43.9 H on unenhanced and contrast-enhanced scans, respectively (Figs. 1 A and 1 B). The mass remained homogeneous at narrow window
settings. Approximately 75% of the circumference projected beyond

Discussion
The true prevalence of hyperdense lesions of the kidney is unknown. Hyperdense cysts are a well-known occurrence in autosomal dominant polycystic kidney disease. In one series

the renal contour,

and the wall of the mass was imperceptible.

Received April 23, 1992, accepted after revision June 23, 1992. The opinions or assertions contained herein are the private views of the authors and are not to be construed as reflecting the view of the Departments Navy or Defense. 1 Department of Radiology, Pennsylvania State University Milton S. Hershey Medical Center, P. 0. Box 850, Hershey, PA 1 7033. Address reprint requests

of the to D.

S. Hartman.
2 3 4 5

Department of Radiology, National Naval Medical Center, Bethesda, MD 20814. Present address: Department of Radiology, Doylestown Hospital, Doylestown, PA 18901. Department of Pathology, National Naval Medical Center, Bethesda, MD 20814. Department of Urology, National Naval Medical Center, Bethesda, MD 20814. December 1992 0361 -803X/92/1596-1 235 American Roentgen Ray Society

AJR 159:1235-1237,

1236

HARTMAN

ET AL.

AJR:159, December

1992

Fig. 1.-A, unenhanced CT scan of left kidney shows a 2.5-cm, round, smooth, homogeneous mass with attenuation of44.5 H. Approximately 75% of circumference of mass extends beyond contour of kidney. B, On enhanced CT scan, mass remains homogeneous and has an attenuation of 43.9 H. C, Photomicrograph shows that near

junction

of cystic

mass and kidney, tulayer of neopapillary exmagnification

mor is lined by a single plastic cells. Laterally,

crescences x85)

of tumor project into lumen

of cyst. (H and E, original

D, Photomicrograph shows that papillary fronds are lined by a single layer of neoplastic clear cells exhibiting lownuclear-grade atypia. (H and E, original

magnification x350)

D
window settings to be certain it is homogeneous in attenua-

of patients with autosomal dominant polycystic kidney disease, almost 70% had one or more high-density cysts (5884 H) [5]. Most other pathologically proved cases of hyperdense cysts have been reported as isolated cases or as part of a small series [2]. Another factor obscuring the true preyalence of hyperdense Cysts iS that they may be isodense on contrast-enhanced scans. If the enhanced scan is not preceded with an unenhanced scan, the diagnosis may be missed. Several mechanisms exist by which renal cysts may become hyperdense. Proposed mechanisms by which cysts have elevated CT attenuation include hemorrhage with clot retraction, concentration of the protein components of blood, elevation of iron content, colloid formation, infection, and transient iodine accumulation within a simple cyst [6]. The cause of the hyperdense appearance in this case is unknown. The following CT criteria have been proposed for a benign hyperdense cyst: (1) The lesion must be perfectly smooth, round, sharply marginated, and homogeneous, with CT atten-

uation

values

ranging
scans;

from approximately
must

40 H to 90 H on
with narrow

unenhanced

the lesion

be evaluated

tion. (2) The lesion must not enhance when contrast material is administered IV, and its configuration must remain unchanged. (3) The lesion must be 3 cm or smaller. (4) The lesion must extend outside of the kidney (at least one fourth of its circumference) so that the smoothness of some of the wall can be evaluated [1 7]. If any of these criteria are not met, further evaluation (e.g., follow-up, cyst puncture, exploration) is required. When deciding whether a hyperdense cyst is benign or malignant, impeccable technique is required. Partial-volume averaging can become problematic unless the section thickness is less than one half the diameter of the lesion. It is important to regularly calibrate CT attenuation values by using fluid in the gallbladder or unopacified urine in the bladder as an internal standard for water. CT is more reliable than sonography in differentiating benign and malignant hyperdense cystic lesions. Only 50% of hyperdense cysts meet the sonographic criteria for a simple cyst [7]. They often have less through-transmission than a similarsized simple cyst or will have a few scattered internal echoes.
,

AJR:159, December 1992

CYSTIC

RENAL

CELL

CARCINOMA

1237

The false-negative CT findings in this case can be explained by the unremarkable gross appearance of the mass. The lack of nodularity and uneven wall thickness seen in most cancers was not present on gross inspection in this Case. The single partial layer of tumor cells lining the cystic carcinoma is beyond the spatial resolution of CT. Cystic renal cell carcinomas, especially those that are papillary, are usually hypovascular or avascular; this may explain the lack of contrast enhancement in this case. On the basis of this case and review of previously published cases, the majority of lesions fulfilling the above-mentioned criteria are indeed benign [8]. This case shows, however, that the CT findings in benign and malignant hyperdense cystic lesions overlap. Further careful radiologic-pathologic correlative studies are required to fully elucidate the magnitude of this overlap.

REFERENCES
1 . Bosniak MA. The small (3.0cm) renal parenchymal tumor: detection,
diagnosis and controversies. Radiology 1991:179:307-317 Hartman DS, Aronson S. Frazer H. Current status of imaging indeterminate renal masses. Radiol Clin North Am 1991;29:475-496

2.

3. Dunnick

RN, Korobkin

M, Clark WM. CT demonstration

of hyperdense

J Comput Assist Tomogr 1984;8: 1023-1 024 4. Bosniak MA. The current radiological approach to renal cysts. Radiology 1986;158:1-10 5. Levine E, Grantham JJ. High-density renal cysts in autosomal dominant polycystic kidney disease demonstrated by CT. Radiology 1985:154: 477-482

renal carcinoma.

6. Fishman MC, Pollack HM, Arger Ph, et al. High protein content: another cause of CT hyperdense benign renal cyst. J ComputAssist Tomogr 1983;
7:1103-1106

7. Bosniak MA. Commentary.

kidneys. Urol Radiol

Difficulties

in classifying

cystic lesions of the PJ. Cystic

1991;

1991;13:91-93

8. Aronson S. Frazier HA, Baluch JD, Hartman DS, Christenson

renal masses:

usefulness

of the Bosniak classification.

Urol Radiol

13:83-90

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