Stanford School of Medicine

Surgical Pathology Criteria

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Collecting Duct Carcinoma


  • High grade renal adenocarcinoma arising in medulla of the kidney, with a predominantly invasive tubular growth pattern
  • Clearly overlaps morphologically and immunophenotypically with medullary carcinoma but the latter has a distinctive clinicopathologic setting

Alternate/Historical Names

  • Bellini duct carcinoma
  • Carcinoma of the collecting ducts of Bellini

Diagnostic Criteria

  • Metastatic adenocarcinoma must be ruled out in every case
    • Collecting duct carcinoma should be considered a diagnosis of exclusion
  • Firm mass centered on the renal medulla
    • Frequently extends into renal cortex and/or pelvis
  • Predominantly tubular pattern
    • Can have areas of papillary growth
      • Occasionally solid or microcystic
    • Usually single layer of cuboidal lining cells with hobnail nuclei
      • Cytoiplasm usually pale eosinophilic to clear
    • Cytoplasmic mucin may be present
      • Signet ring cells seen in rare cases
    • Rare sarcomatoid cases
      • Defined by presence of a distinct spindle cell component occupying at least one microscopic low-power field (×40)
  • Prominent stromal desmoplasia
    • Frequent mixed acute and chronic inflammation
  • High grade nuclear atypia
    • Equivalent to WHO/ISUP 3 or 4
      • Nuclei lare, vesicular and highly pleomorphic with prominent nucleoli
    • Frequent mitotic figures
    • Dysplastic epithelial lining frequently seen in adjacent collecting duct
  • Infiltrative growth pattern
    • Edge of tumor poorly defined with infiltration of adjacent kidney
    • Extra-renal and vascular invasion frequent
  • Absence of any other renal cell carcinoma pattern or of urothelial carcinoma
  • Cases described as low grade collecting duct carcinomas in the past are better classified as one of the following
  • Renal medullary carcinoma is considered a separate entity
    • Considered by some reports to be a variant of collecting duct carcinoma
    • Overlaps histopathologically with collecting duct carcinoma but is separated based on the following features
      • Occurrence in young patients
      • Association with sickle cell trait
      • Lack of INI1 expression (Cheng 2008) vs retention in 85% of collecting duct carcinoma (Elwood 2011)

Kurt Schaberg MD
John P Higgins MD
Robert V Rouse MD
Department of Pathology
Stanford University School of Medicine
Stanford CA 94305-5342

Original posting/last update: 1/24/11, 11/2/16

Supplemental studies


  • Generally positive for:
      • HMWCK (34BE12), CK7, EMA
      • MUC1, CEA
    • Generally negative for:
      • CD10, Racemase (AMACR)
      • E cadherin, PAZ2, CAIX

      Differential Diagnosis

      Metastatic adenocarcinoma must be ruled out clinically and by immunohistochemistry when possible

      • If multiple, metastsis should be strongly considered

      Papillary Renal Cell Carcinoma Collecting Duct Carcinoma
      Lacks desmoplasia Prominent desmoplasia
      Circumscribed Infiltrative
      Frequently low grade nuclear features High grade nuclear features
      CD10, AMACR/Racemase, PN15/gp200 positive CD10, AMACR/Racemase, PN15/gp200 negative

      Gland-forming Urothelial Carcinoma Collecting Duct Carcinoma
      Adjacent usual urothelial carcinoma or carcinoma in situ frequently present Lacks urothelial components
      May show areas of squamous differentiation No squamous differentiation
      CK20+, p63+, PAX8 infrequent CK20-, p63 14%, PAX8+

      Medullary Carcinoma of the Kidney Collecting Duct Carcinoma
      Frequent solid and/or reticular areas Predominantly tubular and papillary
      Mean age 20-24 Mean age 50-55
      Associated with sickle cell trait/disease No association with sickle cell
      INI negative INI positive in 85%
      OCT3/4 69% positive OCT3/4 negative
      The distinction may be largely clinical as there is considerable morphologic overlap

      Mucinous Tubular and Spindle Cell Carcinoma of the Kidney Collecting Duct Carcinoma
      Cytologically bland tubules Cytologically highly atypical tubules
      Mucinous stroma Desmoplastic stroma
      Circumscribed Aggressively invasive

      Tubulocystic Carcinoma of the Kidney Collecting Duct Carcinoma
      Lacks invasion and desmoplastic stroma Prominent invasion and desmoplastic stroma
      Prominently dilated, cystic spaces Predominantly tubules
      Lacks necrosis and mitotic figures Frequent necrosis and mitotic figures
      Infrequent metastases Frequent metastases at presentation

      Hereditary Leiomyomatosis RCC Papillary Renal Cell Carcinoma

      FH Negative, 2SC Overexpressed

      FH intact, No 2SC over expression

      CK7 negative

      CK7 positive

      Prominent eosinophilic nucleoli
      with a clear perinucleolar halo

      May have prominent nucleoli

      Foamy macrophages uncommon

      Foamy macrophages common

      Average age 36

      Average age 60

    • Both may show predominantly papillary architecture
    • HLRCC-associated RCC more likely to resemble Type 2 PRCC with larger tumor cells, often with higher nuclear grade and eosinophilic cytoplasm
    • Grading / Staging


      • Definitionally high grade (Fuhrman grade 3 or 4)i
        • Grade should be assigned based on the siingle high power field showing the greatest degre of nuclear pleomorphism
        • WHO/ISUP grading system for clear cell and papillary renal cell carcinomas
        • Grade 1 Nucleoli are absent or inconspicuous and basophilic at 400x magnification
          Grade 2 Nucleoli are conspicuous and eosinophilic at 400x and visible but not prominent at 100x
          Grade 3 Nucleoli are conspicuous and eosinophilic at 100x
          Grade 4 Extreme nuclear pleomorphism, multinucleate giant cells, and/or rhabdoid and/or sarcomatoid differentiation
      • Cases described as low grade collecting duct carcinomas are better classified as one of the following
        • Mucinous tubular and spindle cell carcinoma
        • Tubulocystic carcinoma


      • Use TNM
      • Most present with high stage


      • Rare (1-2% of renal tumors)
      • Mean age 50-55
        • Range 13-83
      • Poor prognosis
        • 50% node positive at presentation
        • 20-40% have distant metastases at presentation
        • 14% 10 year survival
          • One report that found same behavior in usual RCC when matched for grade and stage (Karakiewicz)

      Classification / Lists

      Renal epithelial neoplasms


      • Moch H, Humphrey PA, Ulbright TM, Reuter VE eds. World Health Organization Classification of Tumors. Pathology and genetics of tumors of the Urinary System and Male Genital Organs, 4th edition,. IARC Press: Lyon 2016.
      • Murphy WM, Grignon DJ, Perlman EJ. Tumors of the Kidney, Bladder and Related Urinary Structures, Atlas of Tumor Pathology, AFIP Fourth Series, Fascicle 1, 2004
      • Moch H, Humphrey PA, Ulbright TM, Reuter VE eds. World Health Organization Classification of Tumors. Pathology and genetics of tumors of the Urinary System and Male Genital Organs, 4th edition,. IARC Press: Lyon 2016.
      • Srigley JR, Delahunt B. Uncommon and recently described renal carcinomas. Mod Pathol. 2009 Jun;22 Suppl 2:S2-S23.
      • Srigley JR, Eble JN. Collecting duct carcinoma of kidney. Semin Diagn Pathol. 1998 Feb;15(1):54-67.
      • Karakiewicz PI, Trinh QD, Rioux-Leclercq N, de la Taille A, Novara G, Tostain J, Cindolo L, Ficarra V, Artibani W, Schips L, Zigeuner R, Mulders PF, Lechevallier E, Coulange C, Valeri A, Descotes JL, Rambeaud JJ, Abbou CC, Lang H, Jacqmin D, Mejean A, Patard JJ. Collecting duct renal cell carcinoma: a matched analysis of 41 cases. Eur Urol. 2007 Oct;52(4):1140-5.
      • Tokuda N, Naito S, Matsuzaki O, Nagashima Y, Ozono S, Igarashi T; Japanese Society of Renal Cancer. Collecting duct (Bellini duct) renal cell carcinoma: a nationwide survey in Japan. J Urol. 2006 Jul;176(1):40-3.
      • Albadine R, Schultz L, Illei P, Ertoy D, Hicks J, Sharma R, Epstein JI, Netto GJ. PAX8 (+)/p63 (-) immunostaining pattern in renal collecting duct carcinoma (CDC): a useful immunoprofile in the differential diagnosis of CDC versus urothelial carcinoma of upper urinary tract. Am J Surg Pathol. 2010 Jul;34(7):965-9.
      • Kobayashi N, Matsuzaki O, Shirai S, Aoki I, Yao M, Nagashima Y. Collecting duct carcinoma of the kidney: an immunohistochemical evaluation of the use of antibodies for differential diagnosis. Hum Pathol. 2008 Sep;39(9):1350-9.
      • Cheng JX, Tretiakova M, Gong C, Mandal S, Krausz T, Taxy JB. Renal medullary carcinoma: rhabdoid features and the absence of INI1 expression as markers of aggressive behavior. Mod Pathol. 2008 Jun;21(6):647-52.
      • Elwood H, Chaux A, Schultz L, Illei PB, Baydar DE, Billis A, Sharma R, Argani P, Epstein JI, Netto GJ. Immunohistochemical analysis of SMARCB1/INI-1 expression in collecting duct carcinoma. Urology. 2011 Aug;78(2):474.e1-5.
      • Gupta R, Billis A, Shah RB, Moch H, Osunkoya AO, Jochum W, Hes O, Bacchi CE, de Castro MG, Hansel DE, Zhou M, Vankalakunti M, Salles PG, Cabrera RA, Gown AM, Amin MB. Carcinoma of the collecting ducts of Bellini and renal medullary carcinoma: clinicopathologic analysis of 52 cases of rare aggressive subtypes of renal cell carcinoma with a focus on their interrelationship. Am J Surg Pathol. 2012 Sep;36(9):1265-78.
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