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Year : 2012  |  Volume : 28  |  Issue : 3  |  Page : 366-367

Cystic change in clear cell renal carcinoma: Does the proportion affect the prognosis?


Date of Web Publication19-Oct-2012

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How to cite this article:
Kathpalia R. Cystic change in clear cell renal carcinoma: Does the proportion affect the prognosis?. Indian J Urol 2012;28:366-7

How to cite this URL:
Kathpalia R. Cystic change in clear cell renal carcinoma: Does the proportion affect the prognosis?. Indian J Urol [serial online] 2012 [cited 2020 May 28];28:366-7. Available from:

Park HS, Lee K, Moon KC. Determination of the Cutoff Value of the Proportion of Cystic Change for Prognostic Stratification of Clear Cell Renal Cell Carcinoma. J Urol 2011;186:423-9.

   Summary Top

Cystic change is found in 4% to 15% of renal cell carcinomas (RCCs) [1] and in approximately 30% of clear cell variant (ccRCC). [2] RCC with a predominantly cystic pattern of growth, defined as neoplastic cells occupying 25% or less of tumor volume, is considered cystic RCC. Some authors have reported that cystic RCC has more favorable biology than noncystic RCC. [3],[4] Currently multilocular cystic RCC (MCRCC), composed of an entirely cystic lesion, is recognized as a distinct subtype of ccRCC with excellent prognosis.

Park et al. carried out this study to determine an optimal cystic proportion cutoff value so as to define two groups of patients with ccRCC with statistically significantly different outcomes. They reviewed the pathology slides of consecutively resected ccRCCs between 2001 and 2003 excluding MCRCC, clear-cell papillary RCC, ccRCC in patients with von Hippel-Lindau syndrome, dialysis associated cystic RCC, and metachronous ccRCC from the study. A total of 223 patients with ccRCC were identified for analysis and all slides were reviewed by two pathologists. Cysts were defined as dilated spaces filled with amorphous fluid or red blood cells lined by clear tumor cells with a dimension of at least 0.1 cm. Hematoxylin and eosin glass slides of tumors of each case were scanned using a Super Coolscan® 9000 ED film scanner. The digitalized slide images and digital gross pictures were used to quantify the area of the lumina in the cystic component and the total area of the tumor cut surface with ImageJ. The proportion of the cystic component was calculated by dividing the sum of cystic luminal areas by the whole area of the tumor cut surface. Tumors with a cystic component of less than 1% were considered noncystic RCC.

The area under the ROC curve was calculated according to the cystic proportion as a measure to predict a low risk of cancer specific death and progression. The optimal curve threshold matched the cystic percent cutoff point showing improved sensitivity and specificity. ROC curve analysis showed RCCs with a cystic component of more than 5% of the tumor had significantly longer cancer-specific and progression-free survival than those with 5% or less. A cystic proportion of more than 5% of tumor stratified by tumor stage and nuclear grade also showed better cancer specific and progression-free survival. Thus a cutoff of 6% was adopted as the break point of cystic change to stratify cases.

   Comments Top

Cystic renal cell carcinoma is known to have favorable clinical behavior than non-cystic renal cell carcinoma. Cysts are occasionally seen during gross examination of the ccRCC specimen. Sometimes cysts are only apparent after microscopic examination due to obscuring cyst fluid or small cyst size. The presence of cysts is not enough to predict survival until they make up 5% of the tumor. Careful gross and microscopic examinations are needed to detect ccRCC with clinically significant cysts. Recently, the cystic change detected grossly or by low power microscopy was found to be a good prognostic factor for ccRCC. [2] Authors assessed the optimal cut-off value of the proportion of cystic change with prognostic significance for ccRCC. The cystic proportion of the tumor cut surface was calculated objectively and its prognostic significance was evaluated. The ROC curve showed that a cystic percent of between 6% and 10% was appropriate to detect patients with RCC at low risk for cancer mortality and progression. They also had significantly lower stage and lower Fuhrman nuclear grade than patients with tumors with a cystic change of 5% or less (each P < 0.0001).

Thus to conclude, a cystic change of more than 5% of the tumor is an independent, good prognostic factor in patients with ccRCC. Careful pathological examination to detect ccRCC with clinically significant cystic change is needed. This is the first study to show association between the proportion of cystic change in ccRCC and clinical outcome. Besides TNM stage and histological grade of the tumor, it can be an important prognostic factor with favorable outcome in future.

   References Top

1.Hartman DS, Davis CJ Jr, Johns T, Goldman SM. Cystic renal cell carcinoma. Urology 1986;28:145-53.  Back to cited text no. 1
2.Park HS, Jung EJ, Myung JK. The prognostic implications of cystic change in clear cell renal cell carcinoma. Korean J Pathol 2010;44:149-54.  Back to cited text no. 2
3.Han KR, Janzen NK, McWhorter VC, Kim HL, Pantuck AJ, Zisman A, et al. Cystic renal cell carcinoma: Biology and clinical behavior. Urol Oncol 2004;22:410-4.  Back to cited text no. 3
4.Corica FA, Iczkowski KA, Cheng L, Zincke H, Blute ML, Wendel A, et al. Cystic renal cell carcinoma is cured by resection: A study of 24 cases with long-term follow-up. J Urol 1999;161:408-11.  Back to cited text no. 4


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