Difference between revisions of "Kidney tumours"
(create) |
m (→Oncocytoma: format) |
||
Line 233: | Line 233: | ||
=Benign & mimics= | =Benign & mimics= | ||
== | ==Oncocytoma== | ||
===General=== | ===General=== | ||
*Can be difficult to distinguish radiologically from RCC (chromophobe subtype). | *Can be difficult to distinguish radiologically from RCC (chromophobe subtype). | ||
Line 257: | Line 257: | ||
Images: | Images: | ||
*[http://commons.wikimedia.org/wiki/File:Renal_oncocytoma2.jpg High mag. oncocytoma (mediawiki.org)]. | |||
*[http://commons.wikimedia.org/wiki/File:Renal_oncocytoma3.jpg Intermed. mag. oncocytoma (mediawiki.org)]. | |||
*[http://commons.wikimedia.org/wiki/File:Renal_oncocytoma4.jpg Low mag. oncocytoma (mediawiki.org)]. | |||
==Angiomyolipoma== | ==Angiomyolipoma== |
Revision as of 03:18, 22 May 2010
Kidney tumours - includes malignant kidney tumours and benign kidney tumours. Medical renal diseases are dealt with in the medical renal diseases article.
Renal specimens
- Renal biopsy - usually of medical disease (see medical kidney).
- Partial nephrectomy.
- Nephrectomy.
- Nephroureterectomy (includes ureter) - done for urothelial cell carcinoma (UCC) of the renal pelvis and ureteric UCC.
- 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).[1]
Renal cell carcinoma
General
- Relatively common form of cancer.
- Often abbreviated RCC.
Origin
- Proximal renal tubule.
Clinical
- Classically described as a triad:[2]
- Hematuria (most common symptom).
- Abdominal mass.
- Flank pain.
- Frequently picked-up on imaging (incidentaloma) ~ 1/3 of cases.
Risk factors
- Smoking.
- Some chemicals.
- Hemodialysis.
- Male>female (~2:1).
- Hereditary - familial syndromes (see Hereditary RCC).
Subtypes
RCC (renal cell carcinoma) comes in different subtypes:[3]
- 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,
- Collecting duct (Bellini duct) carcinoma (1% of RCC).
Notes:
- Subtype is an independent predictor of mortality - but adds very little to multivariate models with staging information.[4]
- CCRCC tends to be worse than ChRCC and PRCC, probably due to higher incidence of mets.[5]
IHC - is it RCC?
- RCC Ma (+), CD10 (+) -- specific for RCC[6]
IHC - differentiation of types
- clear cell RCC vs. papillary RCC
- CK7 (-ve CCRCC), AMACR (+ve in PRCC)[7]
- papillary RCC type 1 vs. papillary RCC type 2
- ChRCC vs. oncocytoma (ONC)
- ChRCC & renal oncocytoma vs. others
- CD117 (ckit) +ve (100% membrane, ~75% cytoplasmic)[12]
- clear cell RCC vs. chromophobe RCC
- Hale's colloidal iron (+ve in ChRCC)[11]
- CK7 (cell membrane +ve in ChRCC)
Notes:
- One paper[13] describes CD10, parvalbumin, AMACR, CK7 and S100A1 as being useful.
- Another paper I came across:[14]
- ckit (CD117) not useful for differentiating ONC and ChRCC.
Tabular comparison
Selected common tumours of the kidney:[15][16]
Clear cell RCC | Papillary RCC type 1 |
Papillary RCC type 2 |
Chromophobe RCC classic variant |
Chromophobe RCC eosinophilic variant |
Oncocytoma | |
Gross | Golden yellow, solid | friable | friable | light brown | light brown | mahogany/brown, +/-central scar |
Architecture | nests, sheets | papillary, simple | papillary, pseudostratified |
nests, sheets | nests, sheets | nests, sheets |
Nuclear atypia | low-high typically medium-high |
low-medium | medium-high | low-high | low-high | low-medium, round nuclei |
Cytoplasm | clear | eosinophilic | eosinophilic | cobwebs/clear | eosinophilic/cobwebs | eosinophilic/ granular & abundant |
Other | delicate vessels, necrosis common |
histiocytes in fibrovascular cores |
histiocytes 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 classic variant |
PaRCC type 2, mets | PaRCC type 1, mets | clear cell RCC | oncocytoma | chromophobe eosinophilic variant |
Key features | clear cells, vascular | papillae, histiocytes simple epithelium |
papillae, histiocytes, stratified |
perinuc. clearing wispy cytoplasm |
wispy eosinophilic cytoplasm |
eosinophilic, granular cytoplasm |
Notes:
- Cell shape: all have epithelioid morphology.
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[17]
Grading
Grading based on Fuhrman system which considers:[18]
- Nuclear pleomorphism (size, shape),
- Chromatin pattern,
- Nucleoli prominence.
Criteria & grades
- Grade 1: no nucleoli, near 'normal' appearance.
- Grade 2: finely granular chromatin (key feature), no nuclei visible with 10x objective lens.
- Grade 3: nucleoli seen easily (key feature).
- Grade 4: prominent pleomorphism (key feature), hyperchromasia, macronucleoli.
Note: Most tumours are grade 2 & 3.
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
Gross
- Gold/yellow.
- +/-Haemorrhage (common).
- +/-Necrosis (common in large tumours).
Histo.[19]
- Clear cells,
- Solid or trabecular pattern,
- Delicate branching vasculature.
- Hyaline bodies common[20]
- Not common in papillary RCC.
IHC
- CK7-
- CK20-
- Hale's colloidal iron-
- +ve in chromophobe
Note: Hale's colloidal iron does not stain iron... it stains hemosiderin.[21]
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).[22]
Papillary RCC
General
- Often subclassified[23] into type 1 and type 2 -- see below.
- May be abbreviated PRCC.
Epidemiology
- Associated with dialysis associated cystic disease.[24]
Microsopy
Histo.[25]
- Cuboidal or low columnar cell in papillae.
- Interstitial foam cells in vascular cores - key feature.[26]
- Most sensitive and specific feature of PRCC.[27]
- Highly vascular.
Mnemonic HIP: highly vascular, interstitial foam cells, papillae.
Histological subtyping:[28]
- 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.
IHC:
- Commonly AMACR+.[29]
More reading:
Clear cell vs. papillary
- Papillary: +histiocytes, +intracellular hemosiderin, CK7+.
Chromophobe RCC
General
- Sometimes abbreviated ChRCC.
There are two subtypes:[30]
- Classic (type I???)
- Eosinophilic variant (type II???)
Gross
- Tan, light-brown.
- Solitary.
- Well-circumscribed.
Microscopy
Classic Histo.[31][32], 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:[33]
- Eosinophilic (finely granular) cytoplasm.
- Perinuclear clearing - key feature.
- Periphery of cell distinct.
- Smaller cells than classic subtype.
Image: Oncocytic chromophobe RCC (wikimedia.org).
IHC
- CK7+ cell membrane[34]
DDx:
- 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
Features:[35]
- Tubular structures with tapered ends.
- High grade nuclear features (nuclear pleomorphism).
- High mitotic rate.
- Hobnail pattern - cell width smaller at basement membrane than free surface ??? [36]
Urothelial cell carcinoma
- Clinically/radiologically, it may not be possible to differentiate renal pelvis UCC and RCC if the tumour is large.
- Pathologically, this is not very difficult.
- On gross specimens, it is almost always obvious what one is dealing with:
- UCC = nephroureterectomy.
- RCC = nephrectomy or radical nephrectomy.
Benign & mimics
Oncocytoma
General
- Can be difficult to distinguish radiologically from RCC (chromophobe subtype).
- ... and pathologists occasionally struggle like the radiologists.
- Benign tumour - the reason it is excised is... one cannot be certain it isn't a RCC.
Gross
- Brown, mahogany brown.
- 1/3 have a characteristic central scar.[37]
Histology
- Eosinophilic cytoplasm key feature.
- Cells arranged in nests.
- Slightly enlarged nuclei, but no significant pleomorphism (size variation).
- Nuclei uniform and round.[38]
Notes:
- May look like eosinophilic variant of chromophobe RCC -- this is the main DDx.
- May need IHC to differentiate (CK7: oncocytoma = cytoplasm +ve, chromophobe = cell membrane +ve).
Images:
- High mag. oncocytoma (mediawiki.org).
- Intermed. mag. oncocytoma (mediawiki.org).
- Low mag. oncocytoma (mediawiki.org).
Angiomyolipoma
General
- Mostly benign mesenchymal tumour.
- Presentations: flank pain, hematuria, incidentaloma.[39]
- AMLs occur may be elsewhere in the body, e.g. liver,[40] but are most common in the kidney.
Epidemiology
- May be assoc. with tuberous sclerosis -- 70% have an AML.
- When compared to sporadic cases:
- More often bilateral.
- Usually bigger.
- When compared to sporadic cases:
Microscopy
- Muscle.
- Adipose tissue - not always present.[41]
- Blood vessels.
Cytologic features[42]
- Nuclei - round/ovoid.
- Chromatin - bland.
IHC
Additional paper: [41]
Notes:
- There is a suggestion that an epithelioid variant is more worisome,[45] but this is not the case in all studies.[46]
Ki-67 can be used to help distinguish btw 'em -- epithelioid variant Ki-67 +ve.[47]
Xanthogranulomatous pyelonephritis
General
- May mimic RCC (esp. radiologically).
- Usually lower pole ???
- Associated with:
- Occasionally an indication of nephrectomy.[48][49]
- Most common organism (in the context of nephrectomy specimens) - Proteus mirabilis.[49]
Microscopy
- Abundant macrophages.
- +/-Giant cells.
Image:
IHC
- CD68+
- RCC markers (CD10, RCC) all negative
DDx:
- Malacoplakia.
- Basophilic inclusions -- inside or outside of macrophages - often size of RBC or larger (Michaelis-Gutmann bodies).
- RCC.
- Granulomatous disease.
Malacoplakia
Medullary fibroma
General
- Rare.
Epidemiology
- Benign.
Gross
- Small, white well circumscribed nodule in medulla.
Microscopy
- Spindle cells.
Rare stuffs
Metanephric adenoma
- Benign.
Micro
- Nests of cells.
Cystic nephroma
- AKA renal epithelial stromal tumour (REST) and mixed epithelial stromal tumour (MEST).
- Rare - approx. 1.5% of renal neoplasms.[50]
- Benign.
- Prevalence: males > females.
Micro
- Cysts lined by simple epithelium with hobnailing.
- Stroma has an ovarian look:
- Blue (basophilic).
- Spindle cells.
Image: Cystic nephroma (wikimedia.org).
IHC
Features:[50]
- ER+.
- PR+.
- CD10+.
DDx
- Tubulocystic carcinoma.
Mucinous spindle cell carcinoma
- Rare.[16]
Microscopy
- Mucin - may be scant.
- Spindle cells.
See also
References
- ↑ NEED REF.
- ↑ Schmid HP, Szabo J (May 1997). "[Renal cell carcinoma--a current review]" (in German). Praxis (Bern 1994) 86 (20): 837?3. PMID 9312811.
- ↑ PBoD P.1016.
- ↑ PMID 19076149
- ↑ PMID 17886093
- ↑ Zhou M, Roma A, Magi-Galluzzi C (June 2005). "The usefulness of immunohistochemical markers in the differential diagnosis of renal neoplasms". Clin. Lab. Med. 25 (2): 247?7. doi:10.1016/j.cll.2005.01.004. PMID 15848735.
- ↑ 7.0 7.1 Zhou M, Roma A, Magi-Galluzzi C (June 2005). "The usefulness of immunohistochemical markers in the differential diagnosis of renal neoplasms". Clin. Lab. Med. 25 (2): 247?7. doi:10.1016/j.cll.2005.01.004. PMID 15848735.
- ↑ 8.0 8.1 Langner C, Ratschek M, Rehak P, Schips L, Zigeuner R (February 2004). "Expression of MUC1 (EMA) and E-cadherin in renal cell carcinoma: a systematic immunohistochemical analysis of 188 cases". Mod. Pathol. 17 (2): 180?. doi:10.1038/modpathol.3800032. PMID 14657952.
- ↑ Liu L, Qian J, Singh H, Meiers I, Zhou X, Bostwick DG (August 2007). "Immunohistochemical analysis of chromophobe renal cell carcinoma, renal oncocytoma, and clear cell carcinoma: an optimal and practical panel for differential diagnosis". Arch. Pathol. Lab. Med. 131 (8): 1290?. PMID 17683191. http://journals.allenpress.com/jrnlserv/?request=get-abstract&issn=0003-9985&volume=131&page=1290.
- ↑ Pan CC, Chen PC, Ho DM (November 2004). "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". Histopathology 45 (5): 452?. doi:10.1111/j.1365-2559.2004.01962.x. PMID 15500648.
- ↑ 11.0 11.1 Geramizadeh B, Ravanshad M, Rahsaz M (2008). "Useful markers for differential diagnosis of oncocytoma, chromophobe renal cell carcinoma and conventional renal cell carcinoma". Indian J Pathol Microbiol 51 (2): 167?1. PMID 18603673. http://www.ijpmonline.org/article.asp?issn=0377-4929;year=2008;volume=51;issue=2;spage=167;epage=171;aulast=Geramizadeh.
- ↑ Krueger S, Sotlar K, Kausch I, Horny HP (2005). "Expression of KIT (CD117) in renal cell carcinoma and renal oncocytoma". Oncology 68 (2-3): 269-75. doi:10.1159/000086783. PMID 16015044.
- ↑ Martignoni G, Brunelli M, Gobbo S, et al (February 2007). "Role of molecular markers in diagnosis and prognosis of renal cell carcinoma". Anal. Quant. Cytol. Histol. 29 (1): 41?. PMID 17375873.
- ↑ Avery AK, Beckstead J, Renshaw AA, Corless CL (February 2000). "Use of antibodies to RCC and CD10 in the differential diagnosis of renal neoplasms". Am. J. Surg. Pathol. 24 (2): 203?0. PMID 10680888. http://meta.wkhealth.com/pt/pt-core/template-journal/lwwgateway/media/landingpage.htm?issn=0147-5185&volume=24&issue=2&spage=203.
- ↑ GUP PP.281-304.
- ↑ 16.0 16.1 PMID 19494850. Cite error: Invalid
<ref>
tag; name "pmid19494850" defined multiple times with different content - ↑ PBoD P.1016.
- ↑ GUP P.282.
- ↑ PBoD P.1017-8
- ↑ AFIP Renal Tumours Book.
- ↑ Latta Jan 27, '09
- ↑ GUP P.285.
- ↑ GUP P.289.
- ↑ PBoD PP.1017-8
- ↑ PBoD P.1017-8.
- ↑ ALS Feb 9, 2009.
- ↑ Granter SR, Perez-Atayde AR, Renshaw AA (October 1998). <303::AID-CNCR6>3.0.CO;2-7 "Cytologic analysis of papillary renal cell carcinoma". Cancer 84 (5): 303?8. PMID 9801205. http://dx.doi.org/10.1002/(SICI)1097-0142(19981025)84:5<303::AID-CNCR6>3.0.CO;2-7.
- ↑ GUP P.289.
- ↑ ALS Feb 9, 2009.
- ↑ GUP P.293.
- ↑ PBoD P.1016-7
- ↑ GUP P.293.
- ↑ GUP P.293.
- ↑ GUP P.293.
- ↑ GUP P.295.
- ↑ PBoD P.1018.
- ↑ GUP P.302.
- ↑ GUP P.302.
- ↑ PMID 18805573
- ↑ PMID 15498214
- ↑ 41.0 41.1 PMID 15584043
- ↑ PMID 15584043
- ↑ GUP P.324.
- ↑ GUP P.324.
- ↑ PMID 12352384
- ↑ PMID 18852677
- ↑ PMID 18839327
- ↑ 48.0 48.1 Afgan F, Mumtaz S, Ather MH (2007). "Preoperative diagnosis of xanthogranulomatous pyelonephritis". Urol J 4 (3): 169–73. PMID 17987581.
- ↑ 49.0 49.1 49.2 Al-Ghazo MA, Ghalayini IF, Matalka II, Al-Kaisi NS, Khader YS (October 2006). "Xanthogranulomatous pyelonephritis: Analysis of 18 cases". Asian J Surg 29 (4): 257–61. PMID 17098659.
- ↑ 50.0 50.1 PMID 17454754