Most succinate dehydrogenase (SDH)-deficient renal cell carcinomas (RCCs) demonstrate stereotypical morphology characterized by bland eosinophilic cells with frequent intracytoplasmic inclusions. However, variant morphologic features have been increasingly recognized. We therefore sought to investigate the incidence and characteristics of SDH-deficient RCC with variant morphologies. We studied a multi-institutional cohort of 62 new SDH-deficient RCCs from 59 patients. The median age at presentation was 39 years (range 19-80), with a slight male predominance (M:F = 1.6:1). A relevant family history was reported in 9 patients (15%). Multifocal or bilateral tumors were identified radiologically in 5 patients (8%). Typical morphology was present at least focally in 59 tumors (95%). Variant morphologies were seen in 13 (21%) and included high-grade nuclear features and various combinations of papillary, solid, and tubular architecture. Necrosis was present in 13 tumors, 7 of which showed variant morphology. All 62 tumors demonstrated loss of SDHB expression by immunohistochemistry. None showed loss of SDHA expression. Germline SDH mutations were reported in all 18 patients for whom the results of testing were known. Among patients for whom follow-up data was available, metastatic disease was reported in 9 cases, 8 of whom had necrosis and/or variant morphology in their primary tumor. Three patients died of disease. In conclusion, variant morphologies and high-grade nuclear features occur in a subset of SDH-deficient RCCs and are associated with more aggressive behavior. We therefore recommend grading all SDH-deficient RCCs and emphasize the need for a low threshold for performing SDHB immunohistochemistry in any difficult to classify renal tumor, particularly if occurring at a younger age.

Anatomical Pathology Douglass Hanly Moir Pathology Sonic Healthcare Macquarie Park NSW Australia

Aquesta Pathology Toowong QLD Australia

Brigham and Women's Hospital and Harvard Medical School Boston MA USA

Cancer Diagnosis and Pathology Group Kolling Institute of Medical Research St Leonards NSW Australia

Complejo Hospitalario de Navarra Navarra Spain

Department of Pathology and Laboratory Medicine University of Calgary and Alberta Precision Labs Calgary AB Canada

Department of Pathology and Molecular Pathology University Hospital Zurich and University Zurich Zurich Switzerland

Discipline of Pathology Macquarie Medical School Macquarie University Macquarie Park NSW Australia

Fundació Puigvert Universitat Autonoma de Barcelona Barcelona Spain

Houston Methodist Hospital Houston TX USA

Institut de Pathologie Centre de Biologie Pathologie CHRU Lille France

Institute of Pathology Rede D'OR São Luiz and D'Or Institute for Research and Education São Paulo Brazil

Institute of Pathology University Hospital Erlangen Friedrich Alexander University Erlangen Nürnberg Erlangen Germany

Lab Plus Auckland DHB Auckland New Zealand

Leeds Teaching Hospital Leeds UK

Mater Health Brisbane QLD Australia

McGill University Montreal Canada

McMaster University Hamilton Ontario Canada

Medical Faculty and University Hospital Plzen Charles University Prague Plzen Czech Republic

NHLS Bloemfontein Area Bloemfontein South Africa

NHS Lothian Edinburgh Scotland UK

Northwestern University Chicago IL USA

NSW Health Pathology Department of Anatomical Pathology Royal North Shore Hospital NSW Health Pathology St Leonards NSW Australia

Oncocentro Foundation Sao Paulo Brazil

PathCare Mediclinic Bloemfontein Hospital Bloemfontein South Africa

Peking University Shenzhen Hospital Shenzhen China

Queen Elizabeth Hospital Kowloon Hong Kong SAR China

Robert J Tomsich Pathology and Laboratory Medicine Institute Cleveland Clinic Cleveland Ohio OH USA

St Teresa's Hospital Kowloon Hong Kong SAR China

Stanford University Medical Center Stanford CA USA

Sunshine Coast University Hospital Pathology Queensland Birtinya QLD Australia

Sydney Medical School The University of Sydney Sydney Australia

The University of Texas MD Anderson Cancer Center Houston TX USA

TissuPath Pathology Melbourne VIC Australia

Tufts Medical Center Boston MA USA

University of California San Francisco San Francisco CA USA

University of Michigan Ann Arbor MI USA

University of Pennsylvania Philadelphia PA USA

University of Queensland Brisbane QLD Australia

University of Southern California Los Angeles CA USA

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