Kidney tumours: Difference between revisions

'''Kidney tumours''' - includes '''malignant kidney tumours''' and '''benign kidney tumours'''.  Medical renal diseases are dealt with in the [[medical renal diseases]] article.

*Renal biopsy - usually of medical disease (see ''[[medical kidney]]'').

*Radical nephrectomy (includes the [[adrenal gland]]).

In excisions done for tumours, a comment should be made about kidney distant from the tumour. People with less renal mass, i.e. less kidney, are predisposed to focal segmental glomerulosclerosis (FSGS).<ref>NEED REF.</ref>

 

 

*Classically described as a triad:<ref name=schmid>{{cite journal |author=Schmid HP, Szabo J |title=[Renal cell carcinoma--a current review] |language=German |journal=Praxis (Bern 1994) |volume=86 |issue=20 |pages=837?3 |year=1997 |month=May |pmid=9312811 |doi= |url=}}</ref>

**Hematuria (most common symptom).

**Abdominal mass.

 

 

*Clear cell carcinoma (70-80% of RCC) -- abbrev. CCRCC,

*Papillary renal cell carcinoma (10-15% of RCC) -- abbrev. PRCC,

*Chromophobe renal carcinoma (5% of RCC) -- abbrev. ChRCC,  

 

*Subtype is an independent predictor of mortality - but adds very little to multivariate models with staging information.<ref>PMID 19076149</ref>

*RCC Ma (+), CD10 (+) -- specific for RCC<ref>{{cite journal |author=Zhou M, Roma A, Magi-Galluzzi C |title=The usefulness of immunohistochemical markers in the differential diagnosis of renal neoplasms |journal=Clin. Lab. Med. |volume=25 |issue=2 |pages=247?7 |year=2005 |month=June |pmid=15848735 |doi=10.1016/j.cll.2005.01.004 |url=}}</ref>

===IHC - differentiation of types===

** E-cadherin +ve in PRCC type 2<ref name=pmid14657952>{{cite journal |author=Langner C, Ratschek M, Rehak P, Schips L, Zigeuner R |title=Expression of MUC1 (EMA) and E-cadherin in renal cell carcinoma: a systematic immunohistochemical analysis of 188 cases |journal=Mod. Pathol. |volume=17 |issue=2 |pages=180? |year=2004 |month=February |pmid=14657952 |doi=10.1038/modpathol.3800032 |url=}}</ref>

**EMA (MUC1) +ve in PRCC type 1<ref name=pmid14657952/>

** CK7 (ChRCC +ve membrane), CK20, CD15<ref name=pmid15848735/>

** CD15 -- ChRCC 11% +ve vs. ONC 57% +ve<ref name=pmid15500648>{{cite journal |author=Pan CC, Chen PC, Ho DM |title=The diagnostic utility of MOC31, BerEP4, RCC marker and CD10 in the classification of renal cell carcinoma and renal oncocytoma: an immunohistochemical analysis of 328 cases |journal=Histopathology |volume=45 |issue=5 |pages=452? |year=2004 |month=November |pmid=15500648 |doi=10.1111/j.1365-2559.2004.01962.x |url=}}</ref>

** Hale's colloidal iron +ve in ChRCC, usually neg. in ONC<ref name=pmid18603673>{{cite journal |author=Geramizadeh B, Ravanshad M, Rahsaz M |title=Useful markers for differential diagnosis of oncocytoma, chromophobe renal cell carcinoma and conventional renal cell carcinoma |journal=Indian J Pathol Microbiol |volume=51 |issue=2 |pages=167?1 |year=2008 |pmid=18603673 |doi= |url=http://www.ijpmonline.org/article.asp?issn=0377-4929;year=2008;volume=51;issue=2;spage=167;epage=171;aulast=Geramizadeh }}</ref>

*ChRCC & renal oncocytoma vs. others

** CD117 (ckit) +ve (100% membrane, ~75% cytoplasmic)<ref>{{cite journal |author=Krueger S, Sotlar K, Kausch I, Horny HP |title=Expression of KIT (CD117) in renal cell carcinoma and renal oncocytoma |journal=Oncology |volume=68 |issue=2-3 |pages=269-75 |year=2005 |pmid=16015044 |doi=10.1159/000086783 |url=}}</ref>

*One paper<ref>{{cite journal |author=Martignoni G, Brunelli M, Gobbo S, ''et al'' |title=Role of molecular markers in diagnosis and prognosis of renal cell carcinoma |journal=Anal. Quant. Cytol. Histol. |volume=29 |issue=1 |pages=41? |year=2007 |month=February |pmid=17375873 |doi= |url=}}</ref> describes CD10, parvalbumin, AMACR, CK7 and S100A1 as being useful.

*Another paper I came across:<ref>{{cite journal |author=Avery AK, Beckstead J, Renshaw AA, Corless CL |title=Use of antibodies to RCC and CD10 in the differential diagnosis of renal neoplasms |journal=Am. J. Surg. Pathol. |volume=24 |issue=2 |pages=203?0 |year=2000 |month=February |pmid=10680888 |doi= |url=http://meta.wkhealth.com/pt/pt-core/template-journal/lwwgateway/media/landingpage.htm?issn=0147-5185&volume=24&issue=2&spage=203}}</ref>

===Tabular comparison===

Selected common tumours of the kidney:<ref>GUP PP.281-304.</ref><ref name=pmid19494850>PMID 19494850.</ref>

| ||'''Clear cell RCC''' ||'''Papillary RCC<br>type 1''' ||'''Papillary RCC<br>type 2''' ||'''Chromophobe RCC<br>classic variant''' || '''Chromophobe RCC<br>eosinophilic variant''' || '''Oncocytoma'''

|Gross ||Golden yellow, solid || friable || friable ||light brown ||light brown ||mahogany/brown, +/-central scar

|Architecture ||nests, sheets || papillary, simple || papillary,<br>pseudostratified ||nests, sheets ||nests, sheets ||nests, sheets

|Nuclear atypia ||low-high<br>typically medium-high ||low-medium || medium-high ||low-high ||low-high ||low-medium, round nuclei

|Cytoplasm ||clear ||eosinophilic ||eosinophilic ||cobwebs/clear ||eosinophilic/cobwebs ||eosinophilic/<br>granular & abundant

|Other ||delicate vessels,<br>necrosis common ||histiocytes<br> in fibrovascular cores ||histiocytes<br> in fibrovascular cores ||perinuclear clearing, thick vessels ||perinuclear clearing, thick vessels ||in loose fibrous/hyaline stroma

|IHC ||CK7-, EMA+ ||AMACR+, EMA+, CK7+ ||AMACR+, E-cadherin+, CK7- ||CD117+, CK7+ (membrane) ||CD117+, CK7+ (membrane) ||Vimentin-, EMA+

|Main DDx ||chromophobe<br>classic variant ||PaRCC type 2, mets ||PaRCC type 1, mets||clear cell RCC ||oncocytoma ||chromophobe<br>eosinophilic variant

|Key features ||clear cells, vascular || papillae, histiocytes<br>simple epithelium ||papillae, histiocytes,<br>stratified ||perinuc. clearing<br>wispy cytoplasm ||wispy eosinophilic<br>cytoplasm ||eosinophilic, granular cytoplasm

==Hereditary RCC==

# [[Von Hippel-Lindau syndrome]] (clear cell tumours),  

# hereditary clear cell carcinoma (VHL gene),

# hereditary papillary carcinoma (MET proto-oncogene mutation)

Note: ''all'' of the above are autosomal dominant<ref>PBoD P.1016.</ref>

Grading based on '''Fuhrman system''' which considers:<ref>GUP P.282.</ref>

*Nuclear pleomorphism (size, shape),

*Nucleoli prominence.

===Criteria & grades===

*Grade 2: finely granular chromatin (key feature), no nuclei visible with 10x objective lens.

===Fuhrman grading in short===

*1 vs. 2: 2 has granular chromatin.

*2 vs. 3: 3 has nucleoli @ 10x objective.

*3 vs. 4: 4 has pleomorphism/hyperchromasia.

==Clear cell carcinoma==

*Gold/yellow.

*+/-Haemorrhage (common).

*+/-Necrosis (common in large tumours).

===Histo.<ref>PBoD P.1017-8</ref>===

*Clear cells,

*Solid or trabecular pattern,

*Delicate branching vasculature.

*Hyaline bodies common<ref>AFIP Renal Tumours Book.</ref>

**Not common in papillary RCC.

===IHC===

*CK20-

*Hale's colloidal iron-

**+ve in chromophobe

Note: ''[[Hale's colloidal iron]]'' does not stain iron... it stains hemosiderin.<ref>Latta Jan 27, '09</ref>

Clear cell vs. chromophobe

*chromophobe: "translucent" (NOT quite clear), reticulated, +Hale's colloidal iron stain, CK7+ (cell membrane).

Clear cell vs. [[adrenocortical carcinoma]]

*ACC: EMA- (epithelial membrane antigen), cytokeratin mostly neg., inhibin+ (neg. in RCC).<ref>GUP P.285.</ref>

==Papillary RCC==

===General===

*Often subclassified<ref>GUP P.289.</ref> into ''type 1'' and ''type 2'' -- see below.

*May be abbreviated ''PRCC''.

*Associated with ''dialysis associated cystic disease''.<ref>PBoD PP.1017-8</ref>

===Microsopy===

*Cuboidal or low columnar cell in papillae.

*Interstitial foam cells in vascular cores - '''key feature'''.<ref>ALS Feb 9, 2009.</ref>

**Most sensitive and specific feature of PRCC.<ref>{{cite journal |author=Granter SR, Perez-Atayde AR, Renshaw AA |title=Cytologic analysis of papillary renal cell carcinoma |journal=Cancer |volume=84 |issue=5 |pages=303?8 |year=1998 |month=October |pmid=9801205 |doi= |url=http://dx.doi.org/10.1002/(SICI)1097-0142(19981025)84:5<303::AID-CNCR6>3.0.CO;2-7}}</ref>

*Highly vascular.

Mnemonic ''HIP'': '''h'''ighly vascular, '''i'''nterstitial foam cells, '''p'''apillae.

Histological subtyping:<ref>GUP P.289.</ref>

*''Type 1'' - single layer of cells on basement membrane.

** usually low grade nuclear features, i.e. low Fuhrman grade.

*''Type 2'' - pseudostratification of cells.

** Usually high grade nuclear features, i.e. high Fuhrman grade.

*Commonly AMACR+.<ref>ALS Feb 9, 2009.</ref>

*[http://www.e-immunohistochemistry.info/web/Papillary_renal_cell_carcinoma.htm e-immunohistochemistry.info]

===Clear cell vs. papillary===

*Papillary: +histiocytes, +intracellular hemosiderin, [[CK7]]+.

==Chromophobe RCC==

===General===

*Sometimes abbreviated ''ChRCC''.

There are two subtypes:<ref>GUP P.293.</ref>

===Gross===

*Tan, light-brown.

*Solitary.

*Well-circumscribed.

===Microscopy===

Classic Histo.<ref>PBoD P.1016-7</ref><ref>GUP P.293.</ref>, 3 P's [[mnemonic]]:

*Pale cytoplasm, with wisps of eosinophilic material; the cells are not completely clear, they have "cobwebs".

*Perinuclear clearing, i.e. a pale halo surrounds the nucleus - '''key feature'''.

*Periphery of cell distinct, i.e. cell membrane is easy to discern.

Eosinophilic variant:<ref>GUP P.293.</ref>

*Eosinophilic (finely granular) cytoplasm.

*Perinuclear clearing - '''key feature'''.

*Periphery of cell distinct.

*Smaller cells than classic subtype.

Image: [http://commons.wikimedia.org/wiki/File:Oncocytic_chromophobe_rcc_high_mag.jpg Oncocytic chromophobe RCC (wikimedia.org)].

===IHC===

*CK7+ cell membrane<ref>GUP P.293.</ref>

*May appear similar to oncotyoma -- particularily the eosinophilic variant.

**IHC: CK7: chromophobe = cell membrane CK7+; oncoctyoma = patchy cytoplasmic +ve

*Classic ChRCC may be challenging to differentiate from clear cell RCC.

**Perinuclear clearing is ''not'' seen in clear cell RCC.

**ChRCC has wisps in the cytoplasm

==Collecting duct carcinoma==

===Epidemiology===

*Rare.

===Microscopy===

*[[Hobnail pattern]] - cell width smaller at basement membrane than free surface ??? <ref>PBoD P.1018.</ref>

==Urothelial cell carcinoma==

=Benign & mimics=

==Oncocytoma==

===General===

===Gross===

===Histology===

**May need IHC to differentiate (CK7: oncocytoma = cytoplasm +ve, chromophobe = cell membrane +ve).

*[http://commons.wikimedia.org/wiki/File:Renal_oncocytoma2.jpg High mag. oncocytoma (mediawiki.org)].

==Angiomyolipoma==

*Presentations: flank pain, hematuria, incidentaloma.<ref name=pmid18805573>PMID 18805573</ref>

===Epidemiology===

*May be assoc. with tuberous sclerosis -- 70% have an AML.

***Usually bigger.

===Microscopy===

*Adipose tissue - not always present.<ref name=pmid15584043>PMID 15584043</ref>

====Cytologic features<ref>PMID 15584043</ref>====

*Nuclei - round/ovoid.

===IHC===

*There is a suggestion that an ''epithelioid'' variant is more worisome,<ref>PMID 12352384</ref> but this is not the case in all studies.<ref>PMID 18852677</ref>

*May mimic RCC (esp. radiologically).

**History of UTI,<ref name=pmid17987581>{{cite journal |author=Afgan F, Mumtaz S, Ather MH |title=Preoperative diagnosis of xanthogranulomatous pyelonephritis |journal=Urol J |volume=4 |issue=3 |pages=169–73 |year=2007 |pmid=17987581 |doi= |url=}}</ref>

**GU obstruction.<ref name=pmid17098659>{{cite journal |author=Al-Ghazo MA, Ghalayini IF, Matalka II, Al-Kaisi NS, Khader YS |title=Xanthogranulomatous pyelonephritis: Analysis of 18 cases |journal=Asian J Surg |volume=29 |issue=4 |pages=257–61 |year=2006 |month=October |pmid=17098659 |doi= |url=}}</ref>

===Microscopy===

*[http://commons.wikimedia.org/wiki/File:Xanthogranulomatous_pyelonephritis_cd68.jpg Xanthogranulomatous_pyelonephritis - CD68 IHC (mediawiki.org)].

===IHC===

*[[Malacoplakia]].  

**Basophilic inclusions -- inside or outside of macrophages - often size of RBC or larger ([[Michaelis-Gutmann bodies]]).

==Malacoplakia==

{{main|Malacoplakia}}

==Medullary fibroma==

===General===

*Rare.

===Epidemiology===

===Gross===

*Small, white well circumscribed nodule in medulla.

===Microscopy===

=Rare stuffs=

==Metanephric adenoma==

===Micro===

*Nests of cells.

==Cystic nephroma==

*Rare - approx. 1.5% of renal neoplasms.<ref name=pmid17454754>PMID 17454754</ref>

===Micro===

*Cysts lined by simple epithelium with hobnailing.

**''Blue'' (basophilic).

**''Spindle cells''.

===IHC===

*Tubulocystic carcinoma.

*Rare.<ref name=pmid19494850>PMID 19494850</ref>

 

==See also==

==References==