Renal collecting duct carcinoma with extensive coagulative necrosis mimicking anemic infarct: report of a case and the literature review
Renal collecting duct carcinoma with extensive coagulative necrosis mimicking anemic infarct: report of a case and the literature review
Qinqin Xu 0 1
Qinghua Cao 0
Ni Liu 0
Ziwen Fang 2
Ziyin Ye 0
Tingsheng Peng firstname.lastname@example.org 0
0 Department of Pathology, The First Affiliated Hospital of Sun Yat-sen University , No. 58, Zhongshan Road II, Guangzhou 510080 , China
1 Department of Pathology, Guangming New District People's Hospital , Shenzhen 518106 , China
2 Department of Diagnostic Radiology, The First Affiliated Hospital of Sun Yat- sen University , No. 58, Zhongshan Road II, Guangzhou 510080 , China
Collecting duct carcinoma (CDC) with a mass of coagulative necrosis is very rare. We report here a case of CDC with extensive geographic coagulative necrosis mimicking anemic infarct with tumor cells embedded around the necrotic foci in a 73-years-old man. Histopathological examination showed that tumor nests near the necrotic foci were arranged as angulated tubules, tubulopapillary and glandular structures. Neoplastic cells had moderate to abundant eosinophilic cytoplasm and large hyperchromatic nuclei with prominent nucleoli as Fuhrman nuclear grade 3 or 4. The tumor cells were positive for pan-Cytokeratin, Vimentin, E-cadherin, CD10, and CK7, confirming the diagnosis as CDC. The patient is still alive 6 months later from nephrectomy, a long time following up is needed to learn the prognosis. Conclusively, morphology from different portions of the lesion, immunohistochemical stain and the combination analysis of the radiological features is essential to make a precise pathological diagnosis of CDC. And CDC should also be distinguished from clear cell renal cell carcinoma, renal medullary carcinoma, urothelial carcinoma with glandular differentiation, renal neuroendocrine tumor, renal epithelioid angiomyolipoma, renal pigmented paraganglioma and renal mesenchymal chondrosarcoma etc. Virtual Slides: The virtual slide(s) for this article can be found here: http://www.diagnosticpathology.diagnomx.eu/ vs/1264270525975030
Collecting duct carcinoma (CDC); Renal epithelial tumors; Extensive coagulative necrosis; Anemic infarct; Differential diagnosis
Adult renal tumors comprise a range of distinct
clinicopathologic subtypes with differing clinical and/or syndrome
associations, gross, microscopic, immunohistochemical
characteristics. Collecting duct carcinoma (CDC) of the
kidney is an unusual variant of renal cell carcinoma. It
originates from the epithelium of the collecting tubule and
accounts for less than 1% of the incidence of renal
epithelial neoplasms . CDC was firstly reported by Foot and
Papanicolaou in 1949 . And it was formally recognized
as an unique clinicopathologic subtype of RCC following
the report and description of 6 new cases by Fleming and
Lewi in 1986 .
Unlike the majority of renal cell carcinomas, CDC is
characterized by distinct clinicopathological features,
aggressiveness and poor prognosis . A male to female
ratio of approximately 2:1 with a mean age of
occurrence in the sixth decade . Grossly, the tumor is often
centrally located in or near the region of the renal pelvis
and appears gray or white without extensive hemorrhage
[4,5]. The tumor often has irregular infiltrative borders
and no extensive hemorrhage and necrosis [5,6]. The
most common architectural patterns of CDC include
angulated tubules or tubulopapillary structures and
glandular structures . High-grade nuclear features with
pleomorphism and prominent eosinophilic nucleoli as
Fuhrman nuclear grade 3 or 4 are common .
Occasionally, focal necrosis were noted in the foci . In
contrast to previously cases, we present here a CDC case
with extensive necrosis and cystic formation in an old
male patient, which were seldom observed in this type
tumor of kidney. The clinicopathological features of
this case and the differential diagnosis was also been
A 73-year-old man was hospitalized because of right
flank pain. There was no history of cigarette smoking
and no family history of malignancy. No history of
occupational exposure to carcinogens and chronic diseases
and chronic medications was obtained. On admission
the patient appeared to have good general condition
without fever, weight loss and dyspnoea. Physical and
neurological examinations showed no abnormality. The
laboratory results including blood count and
classification, liver and renal function, and tumor markers were
within the normal range. Computed tomography showed
a 2.53.4 cm complex solid/cystic mass in the upper
right kidney invading renal sinus and peri-renal tissue,
which was an ill-defined, heterogeneous mass with
central cystic formation (Figure 1, Arrow showed). Chest
and abdominal x-ray were normal for lung and other
abdominal organs. A preoperative presumed diagnosis
was renal coagulative necrosis or tumor and a radical
right nephrectomy was performed.
Material and methods
The specimen was fixed in a 10% neutral formalin
solution and embedded in paraffin. Four micrometer-thick
sections were prepared and stained with
hematoxylineosin. An Envision two-step assay was used for the
immunohistochemistry staining. Commercially available
monoclonal antibodies were employed: Pan Cytokeratin
(Mouse mAb (AE1/AE3); 1:200), Vimentin (Mouse mAb
(V9);1:1000), CD10 (Mouse mAb (56C6); 1:200),
ECadherin (Mouse mAb(NCH-38);1:200), CK7(Mouse mAb
(OV7L12/30);1:200), CK20 (Mouse mAb(Ks20.8);1:200),
CD31(Mouse mAb(JC70A);1:200), CD34 (Mouse mAb
(QBEnd10); 1:200), Actin (MousemAb(1A4); 1:200), CD56
(Mouse mAb(123C3); 1:200), CgA (Rabbit pAb; 1:200),
MelanA (Mouse mAb(A103); 1: 200), HMB45 (Mouse
mAb(HMB45); 1: 200), Ki-67 (Mouse mAb(MIB-1);1:200).
All the primary antibodies and HRP-conjugated secondary
antibodies were obtained from DAKO Inc., Denmark.
Gross examination of the kidney revealed a kidney
measuring 10.0 7.5 5.5 cm. On cut section of the
specimen, a 2.5 2.5 2.0 cm pale mass was mainly
found in the upper part of kidney and near hilus renalis.
The mass appeared as a firm grayish yellowish, solid and
cystic nodule with irregular borders and extensive
geographic coagulative necrosis, infiltrating renal sinus
and peri-renal fat (Figure 2A).
Histological examination revealed extensive geographic
coagulative necrosis with the contour of the necrotic
tissues and a large amount of debris of the dead cells.
This image was firstly considered as kidney anemic
infarct by some pathologists. A few atypical cell nests
embedded in the edge of the necrotic foci and the wall
of the cyst were carefully found, which caused the
caution as a tumor (Figure 2B). More 10 samples taken
from the whole rest mass had been analyzed, and there
were much more tubules or angulated glands irregularly
infiltrating the renal parenchyma with a prominent
interstitial growth pattern, which were interweaved with
the normal kidney tubules around the necrotic foci
(Figure 2C). It was confirmed to be a malignant tumor
that many cells in the irregular glands showed moderate
to abundant eosinophilic or clear cytoplasm and large
hyperchromatic nuclei with prominent nucleoli, which
were of Fuhrman nuclear grade 3 or 4. (Figure 2D). On
rare occasions, Hobnail nuclei were noted in the fibrous
background (Figure 2E). Microabscess like necrosis was
occasionally seen with scatted atypical cells (Figure 2F).
The desmoplasia was accompanied by a predominantly
lymphocytic or occasionally mixed inflammatory
infiltrate including neutrophils and eosinophils.
Immunohistochemical staining showed atypical cell
nests were positive for both CK (Figure 3A) and Vimentin
Figure 1 CT images. (A) Axial contrast-enhanced nephrographic-phase CT image obtained at level of renal hilum shows an ill-defined,
heterogeneous mass with central cystic change involving the parenchyma of the right kidney, with extension into the renal pelvis and right vein.
(B) Reconstructed coronal contrast-enhanced CT image obtained during the excretory phase shows the compression and distortion of the
Figure 2 Morphology of this renal tumor. (A) Macroscopic appearance of the tumor. A global firm grayish yellowish tumor in the upper part
of kidney and near hilus renalis, involving the renal medulla and the cortex. (B) Histological feature of the tumor showed large areas of
geographic coagulative necrosis of kidney (H&E 100). (C) Tubules or angulated glands irregularly infiltrating the renal parenchyma with a
prominent interstitial growth pattern (H&E 200). (D) Tumor cells with abundant eosinophilic cytoplasm and large hyperchromatic nuclei with
prominent nucleoli (H&E 400). (E) Hobnail nuclei were noted in the fibrous background (H&E 400). (F) Microabscess like necrosis was
occasionally seen with scattered atypical cells (H&E 400).
Figure 3 Immunohistochemistry staining for the invasive tumor. (A) pan-CK, (B) Vimentin, (C) E-Cadherin and (D) CD10 staining (IHC 200).
(Figure 3B), partly positive for E-cadherin (Figure 3C),
and weakly positive for CD10 (Figure 3D) and CK7
(not shown). They were also negative for CD31, CD34,
CD56, CgA, Actin, Melan-A, HMB-45, and CK20. MIB
was up to 20% in the tumor cells.
Immunohistochemical staining helped to find the involvement of the
glomeruli and the vascellum by malignant tumor cells.
Based on these histological and immunohistological
findings, this lesion was coincident with the diagnosis
as collecting duct carcinoma (CDC) of Bellini of the
kidney, not anemic infarct.
Collecting duct carcinoma (CDC) of the kidney is a rare
renal cell carcinoma. Occasionally, focal necrosis were
noted in the foci , while CDC with extensive
coagulative necrosis is very rare. In this case, because of the
extensive geographic coagulative necrosis, it was easily
to be misdiagnosed as renal anemic infarct at the first
As known, kidney anemic infarcts tend to be
wedgeshaped foci with the occluded vessel at the apex and the
periphery of the kidney forming the base, and there are
no cellular atypia in the surrounding normal tissue .
In this case, with sufficient resections from different
portions, the atypical tumor cells were seen to infiltrate
the upper and middle renal calyxes, and involve the
glomeruli and the vascellum. The coagulative necrosis
foci was also different from infarct either in shape or the
characteristics. The difference between CDC and kidney
anemic infarct was shown in Table 1.
Immunohistochemical staining showed that the tumor cells were
positive for CK, Vimentin, partly positive for E-cadherin,
weakly positive for CD10 and CK7, which was basically
consistent with the literature . After the exclusion of
the other tumors of kidney, we made the final diagnosis
as kidney collecting duct carcinoma.
The diagnostic criteria of CDC have not yet been fully
established, it is often difficult and, to some extent, is
one of exclusion (See Table 2 in detail). CDC is an
aggressive tumor, sometime with extensive multi-organ
metastasis including the lung, liver, spleen, bone marrow,
adrenal gland, para-aortic lymph node, proximal ureter,
and meninges, resulting in complex presentation [10,11].
Therefore the prognosis of CDC is poor, with
approximately 70% of patients dying of disease progression within
2 years after diagnosis [12,13]. In this case, the patient is
still alive 6 months later from nephrectomy, so that a long
time following up is needed to judge the exact prognosis.
Because there were tumor areas composed with clear
cells, clear cell renal cell carcinoma (CCRCC) should be
eliminated too. CCRCC is a typically globular tumor
which commonly protrude from the renal cortex as a
round mass, tending to be well-circumscribed expansile
lesions invariably with a pseudocapsule. It is in
contradistinction to the infiltrative nature of collecting
duct carcinoma . Immunohistochemical staining was
distinguishable to show that tumor cells of CCRCC
diffusely positive for CD10, vimentin and negative for
Ecadherin, CK7, CK20, while that of CDC are positive for
E-cadherin, CK7, vimentin, partially CD10, and negative
for CK20 .
Renal medullary carcinoma is another distinctive tumor
needed to be distinguished with CDC. Renal medullary
carcinoma occurs in younger cohort mainly in the third
decade of life, with a strong male predominance (10:1)
individuals of African ancestry, and all the patients had
hemoglobin abnormalities and much shorter median
survival [1,14]. There is marked overlap on clinical features,
histology, immuno-phenotype, patterns of metastases, and
uniformly aggressive outcome between collecting duct
carcinoma and renal medullary carcinoma, suggesting a
close interrelationship between them. By some views,
renal medullary carcinoma is considered as a distinctive
clinicopathologic subtype within the aggressive category
of carcinoma of collecting ducts of Bellini .
Urothelial carcinoma of the renal pelvis with glandular
differentiation or urothelial adenocarcinoma invading
the renal parenchyma may elicit desmoplastic response,
thus resembling collecting duct carcinoma. In this case,
the tumor cells were positive for both CK and vimentin,
and weakly positive for CD10. Because urothelial
carcinoma cells are positive for CK, not for vimentin and
CD10, it was not so difficult to make proper diagnosis
with immunohistochemical markers .
Renal primary neuroendocrine tumor (NET) also have
trabecular nests or solid nests. The tumor cells were largely
polygonal with clear cytoplasm and indistinguishable
Coagulative necrosis with the contour of the necrotic
tissue with no cellular atypical features
Table 1 Comparison of the morphological difference between kidney CDC in this case and anemic infarct of kidney
Collecting duct carcinoma (CDC) of kidney in this case
A firm grayish yellowish, solid and cystic nodule with irregular
borders and extensive geographic coagulative necrosis
Atypical tubules or angulated glands around the coagulative necrotic
foci, irregularly infiltrate the renal parenchyma with a prominent
interstitial growth pattern; Tumor cells have moderate to abundant
eosinophilic or clear cytoplasm and large hyperchromatic nuclei with
high nuclear grade
Table 2 Comparison of the immunohistochemical features of kidney CDC and other differential diagnosis
Urothelial carcinoma Less common type of urothelial carcinoma. True glandular spaces present, tubular or enteric
with glandular A tumor with mixed glandular and glands with mucin secretion. Tumor cells have
differentiation or urothelial differentiation is definited moderate to abundant cytoplasm and large
Urothelial hyperchromatic nuclei
Rare renal tumor. Occurs in adults Trabecular nests or solid nests. Largely polygonal CK CgA Syn
(average 60 years), with no sex predilection tumor cells with granular clear cytoplasm and NSE (weakly)
round to oval uniform nuclei with rare mitotic
More than a half have a history of
tuberous sclerosis; both sexes are equally
affected, the mean age is 38 years
Round to polygonal tumor cells arranged in
sheets, with abundant granular cytoplasm and
enlarged vasicular nuclei often with prominent
Melan-A HMB-45 CK CK7
Actin (partly) E-cadherin
Very rare renal tumor
Tumor cells arranged in nests (Zellballen), delicate CD56 CgA
fibrovascular stroma, large round or polygonal Syn S-100
tumor cells with round or oval nuclei (sustentacular
Undifferentiated spindle to oval shaped cells,
and islands of cartilage
A male to female ratio of approximately 2:1 Angulated tubules or tubulopapillary and
with a mean age of occurrence in the sixth glandular structures associated with a
decade desmoplastic stroma; Large irregular tumor
cells with abundant eosinophilic or clear
cytoplasm and large hyperchromatic nuclei
with prominent eosinophilic nucleoli
Occurs in adults (average 70 years), often Solid, alveolar and acinar patterns, containing
associated with VHL disease. The tumor are a network of small thin-walled blood vessels.
typically multi-focal and bilateral The tumor cells have abundant clear
cytoplasm with round and uniform nuclei
A rare tumor. Occurs in younger cohort
mainly in the third decade of life, all the
patients had sickle cell trait and
cytoplasmic boundaries . Sometime the large polygonal
tumor cells of CDC may be indistinguishable from them.
But the nuclei of NET are round to oval and uniform in
size, the mitotic figures are rare. The positive staining of
pan-CK and neuroendocrine marker as CgA and Syn are
helpful to make the right diagnosis.
The tumor cells of epithelioid angiomyolipoma (AML)
are round to polygonal with abundant granular
cytoplasm and enlarged vasicular nuclei often with
prominent nucleoli, which may be initially misdiagnosed as a
high grade carcinoma as CDC. Although almost all the
epithelioid angiomyolipoma lack classical tri-phasic AML
areas, it can be distinguished from CDC by
immunohistochemical positive staining for Melan-A and HMB-45, and
partly Actin .
Another non-epithelial tumors as renal pigmented
paraganglioma and renal mesenchymal chondrosarcoma
should be ruled out from the differential diagnosis. Renal
pigmented paraganglioma  has the typical features of
paraganglioma. The tumor cells were characteristically
arranged in nests (Zellballen) or trabecular patterns
bound by a delicate fibrovascular stroma. They are also
large round or polygonal with round, oval, hyperchromatic
nuclei. Approximately two-thirds of the tumor cells
showed some degree of pigmentation. Prussian blue
staining is useful to show the abundant iron in cytoplasmic.
The tumor cells are positive for CD56 and CgA, which is
helpful to distinguish from the CDC tumor cells.
Mesenchymal chondrosarcoma of kidney is a very rare
tumor of kidney , which is consisted of
undifferentiated spindle to oval shaped cells, with hyperchromatic
nuclei and scanty cytoplasm mainly arranged in Ewings
sarcoma-like, lamellar or hemangiopericytomalike patterns.
This pattern might be confused with CDC. Mesenchymal
chondrosarcoma has also other areas demonstrated well
defined islands of cartilage, which is totally different from
CDC. Herein, sufficient resection from the sample is
essential. The lack of immunoreactivity for epithelial markers as
cytokeratin AE1/E3, EMA and E-cadherin is the important
marker for the differential diagnosis.
Collecting duct carcinoma of Bellini of kidney is a rare
but highly aggressive renal neoplasm arising from the
distal portion of the nephron. The tumor cells of CDC
may invade the vascular, leading to large area coagulative
necrosis, which might be misdiagnosed as kidney infarct.
On the other hand, the diagnosis of CDC should not be
made before the exclusion the other kidney lesions.
Written informed consent was obtained from the patient
for publication of this Case Report and any
accompanying images. A copy of the written consent is available for
review by the Editor-in-Chief of this journal.
QX carried out pathological examination, drafted the manuscript and
performed the literature review; QC performed the literature review and
collected the patients clinical information; NL carried out the
immunohistochemical staining; ZF provided the radiological datas; ZY
participated in pathological investigations and helped to draft the
manuscript .TP gave and reviewed the final histopathological diagnosis,
and revised the manuscript. All authors have read and approved the
The authors thank Dr. Zhaohui Zhang for the radiological support and
Dr. Zhi Li for the suggestion and revision for the manuscript.
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