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1 Department of Radiology, Asan Medical Center, University of Ulsan, 388-1
Poongnap-dong, Songpa-gu, Seoul, 138-736, South Korea.
2 Department of Urology, Asan Medical Center, University of Ulsan, Songpa-gu,
Seoul, 138-736, South Korea.
3 Department of Pathology, Asan Medical Center, University of Ulsan, Songpa-gu,
Seoul, 138-736, South Korea.
Received September 21, 2001;
accepted after revision December 28, 2001.
Address correspondence to K.-S. Cho.
Abstract
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MATERIALS AND METHODS. We reviewed CT scans of four subtypes of renal cell carcinoma: 76 conventional (clear cell), 19 papillary, 13 chromophobe, and two collecting duct. Biphasic CT scans (unenhanced, corticomedullary, and excretory phase scans) were obtained in 61 patients, and monophasic CT scans (unenhanced and excretory phase scans) in 49. We compared patient age and sex; tumor size; degree and pattern (homogeneous, heterogeneous, predominantly peripheral) of enhancement; presence or absence of calcification; and tumor-spreading patterns including perinephric change, venous invasion, and lymphadenopathy in four subtypes.
RESULTS. Conventional renal carcinoma showed stronger enhancement than the other subtypes (p < 0.05): 106 ± 48 H (mean ± SD) in the corticomedullary phase and 62 ± 25 H in the excretory phase. The sensitivity and specificity for differentiating conventional renal carcinoma from the other subtypes were 74% and 100% when 84 H was used as the cutoff value in the corticomedullary phase and 84% and 91% when 44 H was used as the cutoff value in the excretory phase. Conventional (84%), papillary (74%), and collecting duct (100%) renal carcinomas tended to show heterogeneous or predominantly peripheral enhancement, whereas chromophobe renal carcinoma (69%) usually showed homogeneous enhancement. Calcification was more common in papillary (32%) and chromophobe (38%) renal carcinomas than in conventional renal carcinoma (11%) (p < 0.05). Perinephric change and venous invasion were not noted in chromophobe renal carcinoma, whereas both were common in collecting duct renal carcinoma.
CONCLUSION. For the differentiation of the subtypes of renal cell carcinoma, degree of enhancement is the most valuable parameter; enhancement pattern, the presence or absence of calcification, and tumor-spreading patterns can serve supplemental roles in the identification of the subtype of renal cell carcinoma.
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CT has been widely used for the evaluation of renal cell carcinoma because it can provide detailed information about the tumor itself and whether it has extended into perinephric fat or the renal vein. Furthermore, with the use of helical CT, it is possible to analyze the dynamic enhancement pattern of the tumor [17]. Although many reports about the CT features of renal cell carcinoma have been published, to our knowledge only two previous studies have attempted to differentiate the subtypes of renal cell carcinoma [18, 19]. In both reports, researchers stated that stronger enhancement was a unique CT finding for the differentiation of conventional renal carcinoma from the other subtypes [18, 19]. However, further investigation appears to be necessary because in previous studies the current World Health Organization classification system [3, 4] of renal cell carcinoma was not used, various CT findings were not completely evaluated, and differentiation among the subtypes of nonconventional renal carcinomas was not attempted.
In the current study, we compared contrast-enhanced helical CT findings in four subtypes of renal cell carcinoma and investigated which CT findings are helpful in differentiating among these subtypes.
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CT Examination
All CT examinations were performed using a helical CT scanner (Somatom
Plus-S; Siemens, Erlangen, Germany). CT scans were obtained during patient
breath-holding with the following parameters for imaging acquisition and
reconstruction: 120 kVp; 210 mA; section collimation, 5 mm; table feed, 7
mm/sec; and reconstruction interval, 5 mm. All patients received 500-900 mL of
oral contrast material (E-Z CAT [2% barium sulfate suspension]; E-Z EM,
Westbury, NY) 30 min before CT and 120 mL of IV contrast material (Iopamiro
300 [iopamidol]; Bracco, Milano, Italy); the IV contrast material was injected
into an antecubital vein using a mechanical injector at a rate of 3.0
mL/sec.
Sixty-one patients (43 patients with conventional renal carcinoma, 10 with papillary renal carcinoma, seven with chromophobe renal carcinoma, and one with collecting duct renal carcinoma) underwent biphasic CT, which included unenhanced, corticomedullary, and excretory phase scanning. The other 49 patients underwent monophasic CT, which included unenhanced and excretory phase scanning. Scanning of the entire kidney was performed in every phase during approximately 20-23 sec of patient breath-holding. Immediately after the scanning for the excretory phase, scanning covering the lower abdomen and pelvis was performed. Scanning for the corticomedullary phase was started 30 sec after IV contrast injection, and scanning for the excretory phase was started 120 sec after contrast injection.
Image Analysis
Two experienced genitourinary radiologists who were not aware of the renal
cell carcinoma subtype reviewed the CT scans at a picture archiving and
communication system (Radpia; Hyundai Information & Technology, Seoul,
Korea), which made it possible to measure the length and CT number of a lesion
in a particular region of interest. In four subtypes of renal cell carcinoma,
we compared the patient age and sex; tumor size; degree and pattern
(homogeneous, heterogeneous, predominantly peripheral) of enhancement; the
presence or absence of calcification; and the tumor-spreading patterns
including perinephric change, venous invasion, and lymphadenopathy.
To evaluate the degree of enhancement of a tumor, the first radiologist measured the attenuation of three separate regions of interest and calculated the mean of these three values. The locations of the regions of interest were decided by consensus of the two radiologists. One location for measuring the attenuation value was the solid enhancing area in the excretory phase. A round or elliptic region-of-interest cursor was placed over an enhanced area, which was at least 1 cm2 and consistent in location during all phases of CT. We tried to cover the enhanced area as much as possible in the region of interest and to exclude the area of calcification from the region of interest. The degree of enhancement was measured by calculating the difference in the mean attenuation values between the corticomedullary and unenhanced phase scans (n = 61) and between the excretory and unenhanced phase scans (n = 110).
The enhancement pattern of the tumor was classified as homogeneous, heterogeneous, or predominantly peripheral. Homogenous enhancement was indicated when most areas in the tumor showed a uniform degree of enhancement. Predominantly peripheral enhancement was considered when most portions of the tumor were not enhanced and only the peripheral rim or septa showed enhancement. The remaining cases were considered to have heterogeneous enhancement.
The enhancement pattern of a tumor is generally affected by its size; the larger a tumor grows, the more frequently intratumoral necrosis or hemorrhage occurs [20]. To eliminate the influence of tumor size on enhancement pattern, we divided tumors into the following groups according to maximum diameter: less than 3 cm, 3-7 cm, and greater than 7 cm. Thereafter, we compared the enhancement pattern of the four subtypes of renal cell carcinoma in the three groups.
Perinephric change was indicated when there was evidence of strands of soft-tissue attenuation or parasitized vessels in the perinephric area and thickening of Gerota's fascia. Venous invasion was indicated when the lumen of the renal vein or the inferior vena cava was replaced by the tumor. Lymphadenopathy was considered to be present when a lymph node was enlarged more than 1 cm in diameter.
Statistical Analysis
Statistical analysis was performed for comparison of the various CT
findings of conventional renal carcinoma, papillary renal carcinoma, and
chromophobe renal carcinoma. Collecting duct renal carcinoma was excluded from
the statistical analysis because the patient population was too small. We
applied the one-way analysis of variance test for comparison of patient age,
tumor size, and the degree of tumor enhancement. To evaluate the diagnostic
validity of the degree of enhancement in differentiating subtypes of renal
cell carcinoma, we generated receiver operating characteristic curves and
analyzed these curves to determine the cutoff value for differentiating the
subtypes of renal cell carcinoma with highest accuracy. The chi-square test
was used for comparison of the distribution of patient sex; the frequency of
each enhancement pattern; the presence or absence of calcification; and
tumor-spreading patterns including perinephric change, venous invasion, and
lymphadenopathy in three subtypes of renal cell carcinoma.
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The mean tumor diameter ± the standard deviation was 5.7 ± 2.5 cm (range, 1-14 cm) in conventional renal carcinoma, 6.4 ± 4.2 cm (range, 1-14 cm) in papillary renal carcinoma, 7.2 ± 2.7 cm (range, 2-13 cm) in chromophobe renal carcinoma, and 10.9 ± 0.6 cm (range, 10-12 cm) in collecting duct renal carcinoma. The tumor size was not significantly different in conventional, papillary, and chromophobe renal carcinomas (p > 0.05).
The attenuation values and the degree of enhancement of the four subtypes of renal cell carcinoma are summarized in Table 1. The attenuation values of conventional, papillary, and chromophobe renal carcinomas did not differ on unenhanced scans (p > 0.05) (Figs. 1A, 2A, 3A, 4A, and 5A). On the corticomedullary phase scans, both the attenuation value and degree of enhancement were higher in conventional renal carcinoma (Figs. 1B and 2B) than in papillary renal carcinoma (p = 0.011 for attenuation value and p = 0.012 for degree of enhancement) (Figs. 3B and 4B) and in chromophobe renal carcinoma (p = 0.013 for attenuation value and p = 0.010 for degree of enhancement) (Fig. 5B). On the excretory phase scans, both attenuation value and degree of enhancement were also higher in conventional renal carcinoma (Figs. 1C and 2C) than in papillary renal carcinoma (p = 0.001 for attenuation value and p = 0.000 for degree of enhancement) (Figs. 3C and 4C) and in chromophobe renal carcinoma (p = 0.000 for attenuation value and p = 0.000 for degree of enhancement) (Fig. 5C). No statistically significant difference between papillary and chromophobe renal carcinomas was detected in attenuation value or degree of enhancement in either the corticomedullary phase or the excretory phase (p > 0.05). Although statistical analysis could not be performed, both the attenuation value and degree of enhancement of collecting duct renal carcinoma were similar to those of papillary and chromophobe renal carcinomas.
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The receiver operating characteristic curves for the degree of tumor enhancement in differentiating conventional renal carcinoma from nonconventional renal carcinomas are illustrated in Figure 6A,6B. The area under the curve (Az value) for the corticomedullary phase was 0.833 (95% confidence interval [CI]: 0.702-0.923) and that for the excretory phase was 0.905 (95% CI: 0.825-0.956). In the receiver operating characteristic curve analysis, the cutoff value with the highest accuracy for the differentiation of conventional renal carcinoma from nonconventional renal carcinomas was 84 H in the corticomedullary phase and 44 H in the excretory phase. The diagnostic test statistics for those values are listed in Table 2.
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The enhancement patterns of the four subtypes of renal cell carcinoma are summarized in Table 3. Heterogeneous or predominantly peripheral enhancement was frequent in conventional (84%), papillary (74%), and collecting duct (100%) renal carcinomas, whereas homogeneous enhancement was commonly noted in chromophobe renal carcinoma (69%). Statistically, the frequency of heterogeneous enhancement was significantly higher in conventional renal carcinoma (68%) than in chromophobe renal carcinoma (23%) (p = 0.000), whereas the frequency of homogeneous enhancement was higher in chromophobe renal carcinoma than in conventional renal carcinoma (p = 0.000) and papillary (p = 0.016) renal carcinomas. The frequency of predominantly peripheral enhancement was similar in conventional, papillary, and chromophobe renal carcinomas (p > 0.05).
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An analysis of the tumor enhancement patterns according to tumor size is summarized in Table 4. In tumors less than 3 cm in diameter, a heterogeneous or predominantly peripheral enhancement pattern was noted in 10 patients (56%) with conventional renal carcinoma (Fig. 1A,1B,1C), whereas four of five papillary renal carcinomas (Fig. 3A,3B,3C) and all chromophobe renal carcinomas showed homogeneous enhancement. In tumors 3-7 cm in diameter, conventional (93%) and papillary (88%) renal carcinomas showed predominantly heterogeneous or predominantly peripheral enhancement pattern, whereas chromophobe renal carcinomas (67%) usually showed homogeneous enhancement. In tumors greater than 7 cm in diameter, the frequency of homogeneous enhancement was higher in chromophobe renal carcinoma (63%) (Fig. 5A,5B,5C) than in conventional renal carcinoma (6%) (p = 0.000) (Fig. 2A,2B,2C) and papillary renal carcinoma (0%) (p = 0.029) (Fig. 4A,4B,4C). At microscopic examination, all tumors with homogeneous enhancement were chiefly composed of solid elements, whereas all tumors with predominantly peripheral enhancement had extensive necrosis or hemorrhage. All tumors with heterogeneous enhancement had both solid elements and necrosis or hemorrhage.
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Calcification within the tumor was noted in eight patients with conventional renal carcinoma (11%), six with papillary renal carcinoma (32%), and five with chromophobe renal carcinoma (38%). The frequency was higher in papillary (Fig. 4A,4B,4C) and chromophobe (Fig. 5A,5B,5C) renal carcinomas than in conventional renal carcinoma (p = 0.021 for papillary renal carcinoma and p = 0.008 for chromophobe renal carcinoma). Neither of the collecting duct carcinomas (n = 2) had calcifications (Fig. 7A,7B,7C,7D).
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In evaluating the tumor-spreading patterns, we observed perinephric change in 13 conventional (17%), four papillary (21%), and two collecting duct (100%) renal carcinomas. Venous invasion was noted in six conventional (8%) and two papillary (11%) renal carcinomas and in one collecting duct (50%) renal carcinoma; all of these cases were also confirmed at pathologic examination. Lymphadenopathy was noted in nine conventional (12%), two papillary (11%), and two chromophobe (15%) renal carcinomas and in one collecting duct (50%) renal carcinoma. In patients with chromophobe renal carcinoma, neither perinephric change nor venous invasion was observed. Statistical analysis revealed that the frequencies of perinephric change, venous invasion, and lymphadenopathy in conventional, papillary, and chromophobe renal carcinomas did not differ significantly (p > 0.05). The CT stage of renal cell carcinoma according to the American Joint Committee on Cancer's system [21] was I (T1 N0 M0) in 58 patients (42 conventional, 11 papillary, and five chromophobe renal carcinomas), II (T2 N0 M0) in 30 (19 conventional, four papillary, and seven chromophobe renal carcinomas), III (T3a,b N0-1 M0) in 18 (13 conventional and four papillary renal carcinomas and one chromophobe renal carcinoma), and IV (T1-3b N2 M0) in four (two conventional and two collecting duct renal carcinomas).
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To our knowledge, until recently, differentiation of the renal cell carcinoma subtypes has been attempted on CT in only two series. Fujimoto et al. [18] analyzed the enhancement pattern of renal cell carcinomas greater than 5 cm in diameter on contrast-enhanced helical CT. They reported that strong enhancement equal to the renal cortex was noted only in conventional renal carcinoma (75%) and not in the other subtypes of renal cell carcinoma. Wildberger et al. [19] evaluated CT findings including tumor nodule, margin, shape, and enhancement to differentiate among the various subtypes of renal cell carcinoma. According to their data, Wildberger et al. found that the sensitivity for differentiating conventional renal carcinoma from nonconventional renal carcinomas was approximately 72%. However, in both of these studies, the subtypes of nonconventional renal carcinomas could not be predicted with the CT criteria being evaluated.
In our study, we found that enhancement pattern is the most useful parameter in differentiating subtypes of renal cell carcinoma, especially conventional renal carcinoma versus nonconventional renal carcinomas, with high validity (Az value > 0.8 in both the corticomedullary phase and the excretory phase). Conventional renal carcinoma showed stronger enhancement than nonconventional renal carcinomas in both the corticomedullary and excretory phases, and the tumors that enhanced more than approximately 84 H in the corticomedullary phase and 44 H in the excretory phase were likely to be conventional renal carcinoma. Although strong enhancement of conventional renal carcinoma has been observed in previous reports [18, 19], the actual values of enhancement for differentiating conventional renal carcinoma from nonconventional renal carcinomas have not, to our knowledge, been reported previously; our study is the first to present these data. Some investigators believe that the strong enhancement of conventional renal carcinoma is caused by its rich vascular network and alveolar architecture at histologic examination [2, 18].
Our study revealed that enhancement pattern, the presence or absence of calcification, and tumor-spreading pattern overlap among the subtypes of renal cell carcinoma. However, in certain circumstances, a combination of these characteristics may be helpful in predicting a specific subtype of renal cell carcinoma. A tumor that is greater than 7 cm in diameter, exhibits homogeneously weak enhancement, and has calcifications is strongly suggestive of chromophobe renal carcinoma. In addition, a tumor with heterogeneously strong enhancement and a diameter of less than 3 cm may indicate conventional renal carcinoma. Different enhancement patterns of renal cell carcinoma according to subtype may be supported by findings at pathologic examination. Chromophobe renal carcinoma, which tends to exhibit homogeneous enhancement on CT, shows a homogenous cut surface without hemorrhage or necrosis and a solid growth pattern at pathologic examination. In contrast, conventional renal carcinoma, which usually shows heterogeneous or predominantly peripheral enhancement on CT, commonly has hemorrhage or necrosis within the tumor at pathologic examination [2, 22].
With regard to the tumor-spreading pattern, chromophobe renal carcinoma did not show any perinephric change or venous invasion. This finding suggests that chromophobe renal carcinoma grows slowly and less aggressively, as has also been shown by other researchers [14, 15]. Crotty et al. [14] reported that 43 (86%) of 50 chromophobe renal carcinomas were discovered in Robson stage I at presentation, and Akhtar et al. [15] reported that 20 of the 21 chromophobe renal carcinomas in their study were T1-2 N0 M0. In fact, in our study the overall frequencies of perinephric change, venous invasion, and lymphadenopathy were lower than those documented in previous reports [1, 5]. This difference in findings might be attributable to the fact that the recently increased use of CT has resulted in earlier detection of renal cell carcinoma than in the past and that the use of contrast-enhanced helical CT has been beneficial for differentiating malignant tumors from unenhanced benign cysts.
Some CT findings are known to be relevant to the prognosis of patients with renal cell carcinoma: hemorrhage and necrosis are predictors of poor prognosis, and calcification suggests a higher 5-year survival rate [1]. Our results agree with these findings because hemorrhage and necrosis (heterogeneous or predominantly peripheral enhancement pattern) were more common in conventional and collecting duct renal carcinomas, both of which are associated with a poor prognosis, than in papillary and chromophobe renal carcinomas, which are associated with a good prognosis. Calcification was more frequently seen in papillary and chromophobe renal carcinomas, which are associated with a better prognosis, than in the other subtypes.
For a preoperative staging workup of a patient with renal cell carcinoma, examinations in addition to abdominal CT—such as chest radiography and bone scanning—are necessary for metastasis survey. The prediction of the subtype of renal cell carcinoma may influence the degree of preoperative evaluation. For example, a patient with a subtype of renal cell carcinoma that tends to not metastasize, such as chromophobe renal carcinoma, may not need to undergo a complex metastasis survey.
For patients with surgically treatable renal cell carcinoma, radical nephrectomy has been indicated as the standard treatment. In spite of improved surgical techniques, postoperative mortality and morbidity remain high. From this point of view, precise preoperative identification of the subtype of renal cell carcinoma may be helpful in determining the appropriate extent of surgery. For example, an unnecessarily wide resection may be avoided in patients with a subtype that is unlikely to recur or metastasize, thereby reducing postoperative morbidity and mortality.
There are some limitations in this study. The major limitation is that the number of papillary, chromophobe, and collecting duct renal carcinomas was relatively small to analyze CT features. In fact, this limitation arises from the significantly lower incidence of these three subtypes of renal cell carcinoma compared with conventional renal carcinoma. Therefore, further investigation with adequate numbers of these three subtypes will be necessary in the future.
One possible criticism of this study is that enhancement of renal cell carcinoma may be variable according to the contrast injection parameter and scan delay time. In a study by Birnbaum et al. [23], in which IV contrast material was administrated using a biphasic technique (injection rate of 3 mL/sec [50 mL] and 1 mL/sec [100 mL] for a total injection time of approximately 117 sec), the degree of enhancement was stronger in the excretory phase than in the corticomedullary phase; these findings dramatically differ from our results. Therefore, our criterion of tumor enhancement pattern is applicable only to those cases in which the contrast injection protocol and scan time are similar to those of our study.
Another minor limitation of this study is that all the patients did not undergo biphasic CT. However, the scanning protocol for the excretory phase was strictly constant in all patients, and the different degrees of enhancement among the subtypes of renal cell carcinoma were noted in the excretory phases as well as in the corticomedullary phase.
In conclusion, the degree of enhancement is the most valuable parameter in differentiating among the subtypes of renal cell carcinoma, and enhancement pattern, calcification, and tumor-spreading patterns may play a supplemental role.
Acknowledgments
We thank Bonnie Hami, of the Department of Radiology, University Hospitals
Health System, Cleveland, OH, for editorial assistance and Wi Chang Kang, of
the Asan Medical Center, University of Ulsan, for statistical advice.
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