Kidney tumours

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

Pediatric kidney tumours are dealt with in the pediatric kidney tumours article.

Renal specimens

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).

Anatomy

The anatomy is important for properly staging renal neoplasms.

Layers (superficial to deep):

  1. Renal fascia (Gerota's fascia).
  2. Perinephric fat.
  3. Renal capsule.
  4. Renal parenchyma (cortex).

Sign out

Missed renal biopsy

KIDNEY (LESION), LEFT, CORE BIOPSY:
- RENAL PARENCHYMA.
- NEGATIVE FOR MASS LESION, SEE COMMENT.

COMMENT:
No mass lesion is apparent in the tissue sampled. A re-biopsy should be considered.

Renal parenchyma:
- Glomeruli: seven glomeruli sampled, no apparent glomerular pathology on the H&E sections.
- Interstitium: interstitial fibrosis is not identified.
- Tubules: no pathology is apparent.
- Vessels: mild atherosclerosis, no hyalinization of arterioles apparent.

Tabular comparison (selected tumours)

Selected common tumours of the kidney:[2][3]

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, "raisinoid"
nuc. membrane 		low-high, "raisinoid"
nuc. membrane 		low-medium, round nuclei
Cytoplasm clear eosinophilic eosinophilic cobwebs/clear eosinophilic/cobwebs eosinophilic/
granular & abundant
Other delicate vessels,
necrosis common 		histiocytes
in fibrovascular cores, >0.5 cm 		histiocytes
in fibrovascular cores, >0.5 cm 		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 		perinuc. clearing,
wispy eosinophilic
cytoplasm 		eosinophilic, granular cytoplasm
Image(s)
CCRCC (WC)
PaRCC - intermed. (WC)
,
PaRCC - high (WC)
ChRCC (WC)
Oncocytoma (WC)

Notes:

  • Cell shape: all have epithelioid morphology.

Tabular comparison of oncocytoma and chromophobe RCC

Histomorphologic features useful to distinguish chromophobe RCC (eosinophilic variant) and oncocytoma:[4]

Morphologic feature ChRCC (eosinophilic
variant) 		Renal oncocytoma
Nuclear morphology "raisinoid"/wrinkled appearance round with small nucleolus,
usu. little size variation
Multinucleation common - binucleation uncommon
Chromatin coarse fine
Architecture solid, crowded nests spaced nests /
archipelago-like, solid
Cytoplasm perinuclear halo, may be focal no perinuclear halo
Degenerative foci
(focal atypia & pleomorphism) 		absent present in ~20% of cases
Image
ChRCC (WC/Nephron)
Oncocytoma (WC/Nephron)

Common DDx

Spindle cell tumours:

WHO classification

  • Based on 2004 iteration - as per WMSP, slightly modified.[5] Online, the classification can found here.

Renal cell tumours

Common:

Less common:

Metanephric tumours

Nephroblastic tumours

Mesenchymal tumours

Childhood:

Adults:

Other:

Mixed mesenchymal and epithelial tumours

Others

Renal cell carcinoma

Overview

General

  • Relatively common form of cancer.
  • Often abbreviated RCC.
  • AKA hypernephroma.[6]
  • RCC represents approx. 90% of malignancies in kidneys of adults.[7]

Origin

  • Proximal renal tubule.

Clinical

  • Classically described as a triad:[8]
    • Hematuria (most common symptom).
    • Abdominal mass.
    • Flank pain.
  • Frequently picked-up on imaging (incidentaloma) ~ 1/3 of cases.

Risk factors

Subtypes of RCC

RCC (renal cell carcinoma) comes in different subtypes:[9]

  • 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.[10]
  • CCRCC tends to be worse than ChRCC and PRCC, probably due to higher incidence of mets.[11]
  • The exam answer (worst to best): clear cell RCC, papillary RCC, chromophobe RCC.

IHC - is it RCC?

  • RCC Ma (+), CD10 (+) -- specific for RCC[12]

IHC - differentiation of types

  • Clear cell RCC vs. papillary RCC:
    • CK7 (-ve CCRCC), AMACR (+ve in PRCC).[13]
  • Papillary RCC type 1 vs. papillary RCC type 2:
    • E-cadherin +ve in PRCC type 2.[14]
    • EMA (MUC1) +ve in PRCC type 1.[14]
  • ChRCC vs. oncocytoma (ONC):
    • CK7 (ChRCC +ve membrane), CK20, CD15.[13]
    • CK7 -- ChRCC 86% +ve vs. ONC 0% +ve.[15]
    • CD15 -- ChRCC 11% +ve vs. ONC 57% +ve.[16]
    • Hale's colloidal iron +ve in ChRCC, usually neg. in ONC.[17]
    • PAX2 -- ChRCC (1/11) +ve vs. ONC (20/23) +ve.[18]
    • Kidney-specific cadherin (Ksp-cadherin) -- ChRCC 97% +ve (distinctive membrane pattern) vs. ONC only 3% +ve.[19]
  • ChRCC & renal oncocytoma vs. others:
    • CD117 (ckit) +ve (100% membrane, ~75% cytoplasmic).[20]
  • Clear cell RCC vs. chromophobe RCC:
    • Hale's colloidal iron (+ve in ChRCC).[17]
    • CK7 (cell membrane +ve in ChRCC).

Notes:

  • One paper[21] describes CD10, parvalbumin, AMACR, CK7 and S100A1 as being useful.
  • Another paper I came across:[22]
  • c-kit (CD117) not useful for differentiating ONC and ChRCC.[18]
  • E-cadherin not useful for differentiating ChRCC and ONC.[23]

RCC vs. Urothelial cell carcinoma

Main article: Urothelium
  • 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 = partial nephrectomy, nephrectomy or radical nephrectomy.

Renal cell carcinoma with sarcomatoid differentiation

  • AKA sarcomatoid renal cell carcinoma.

General

Features:[24]

  • Not recognized as a distinct entity in 2004 WHO classification.[25]
    • It is considered an indicator of progression.
    • Previously considered a distinct entity.[25][26]
  • Tend to present at higher stage.
  • Worse prognosis when adjusted for stage.
  • Fuhrman grade 4 by definition.

Microscopic

Features:[24]

  1. Renal cell carcinoma.
  2. Sarcomatoid component:

Note:

Images:

Renal cell carcinoma with rhabdoid morphology

  • AKA renal cell carcinoma with rhabdoid change.

General

  • Not recognized as a distinct entity.[30]

Microscopic

Features:

  • Rhabdoid cells:
    • Eccentrically placed large round nuclei with very prominent nucleoli.
    • Abundant eosinophilic cytoplasm.

Notes:

  • May be multinucleated.

IHC

Features:[31]

  • Vimentin +ve (23 of 23 cases).
  • NSE +ve (~80% of cases).
  • S-100 -ve/+ve (+ve ~ 40% of cases).
  • Desmin -ve (23 of 23 cases).
  • SMA -ve (~5% of cases).

Hereditary renal cell carcinoma

The classics - which are all autosomal dominant:[9]

  1. Von Hippel-Lindau syndrome.
    • VHL gene mutation.
    • Clear cell RCC.
  2. Hereditary clear cell renal cell carcinoma.
    • VHL gene mutation.
  3. Hereditary papillary renal cell carcinoma.
    • MET proto-oncogene mutation.
    • PaRCC type 1.[32]
  4. Hereditary leiomyomatosis and renal cell cancer:[32]
  5. Birt–Hogg–Dubé syndrome:[32]
    • FLCN (folliculin) gene mutation.[34]
    • Skin lesions (fibrofolliculoma, trichodiscoma, acrochordon).
    • ChRCC most common, other types seen (e.g. oncocytoma).
    • Variable penetrance (autosomal dominant).

Others:

  • Hereditary papillary carcinoma (TFE3 related translocations).[35]

Notes:

  • A total of ten hereditary renal cancer syndromes have been described. In eight of the ten the gene is known.[36]

Molecular

Recurrent molecular changes in RCC:

  • Clear cell RCC:
    • Loss of 3p - contains the VHL gene.
  • Papillary RCC:
    • Sporadic:
      • Trisomy 7, 16, 17.
      • Loss of Y.
    • Familial:
      • Trisomy 7 - contains MET gene.[37]

Renal cell carcinoma grading

  • AKA Fuhrman grade.

General

Some RCC subtypes are graded based on the Fuhrman system which considers:[38]

  • Nuclear pleomorphism (size, shape).
  • Chromatin pattern.
  • Nucleoli prominence.

Notes:

Criteria & grades

Note:

  • Most tumours are grade 2 & 3.

Fuhrman grading in short

  • 1 vs. 2: grade 2 has granular chromatin, grade 2 has nucleoli visible @ 20x objective.[40]
  • 2 vs. 3: grade 3 has nucleoli @ 10x objective.
  • 3 vs. 4: grade 4 has pleomorphism/hyperchromasia (or spindle cells or rhabdoid cells).

Clear cell renal cell carcinoma

Main article: Clear cell renal cell carcinoma

Multilocular cystic renal cell carcinoma

General

  • No recurrences or metastasis in the literature.[41]
    • This makes one wonder... is it really cancer.
  • Case report rare.[42]

Gross

Features:[41]

  • Cystic with thin septa.
  • Well circumscribed.

Note:

  • This tumour, radiologically, can often be separated from other cystic tumours.[43]

Microscopic

Features:[41]

  • Polygonal cells within the septa.
  • Clear cytoplasm.
  • +/-Calcification (common).

DDx:

IHC

  • EMA +ve.
  • Keratins +ve.
  • CD68 -ve.

Papillary renal cell carcinoma

Main article: Papillary renal cell carcinoma

Chromophobe renal cell carcinoma

Main article: Chromophobe renal cell carcinoma

Clear cell papillary renal cell carcinoma

Main article: Clear cell papillary renal cell carcinoma

Unclassified renal cell carcinoma

  • Abbreviated URCC.

General

  • Uncommon.
  • A WHO classification diagnosis of exclusion.
  • Worse prognosis than clear cell renal cell carcinoma.[44]
  • High variation in the prevalence (when comparing institutions); this suggests a lack of uniformity in the diagnosis of this subtype.[44]

Microscopic

Features:

  • Malignant tumour that is one of the following:[45][46]
    1. A combination of other RCC histologic types (~35% of cases of URCC).
    2. Has a "non-identifiable" pattern/unrecognizable cell type (~60% of cases of URCC).
    3. Pure sarcomatoid RCC without an identifiable (epithelioid) RCC subtype (~5% of cases of URCC).[46]

DDx:

Renal translocation carcinomas

Renal tumour with Xp11.2 translocation

Main article: Renal tumour with Xp11.2 translocation

Renal tumour with t(6;11) translocation

General

Microscopic

Features:

  • Hyaline material between nests.
  • Large cells with clear to eosinophilic cytoplasm.

Molecular

  • t(6;11)(p21;q12) Alpha/TFEB.[48]

Benign tumours

Papillary adenoma of the kidney

  • AKA renal papillary adenoma.

General

Microscopic

Features:

  1. Histomorphology of papillary renal cell carcinoma.
  2. Must be <=0.5 cm.[50][51]

DDx:

Images:

IHC

Renal oncocytoma

Main article: Renal oncocytoma

Angiomyolipoma

  • Abbreviated AML.

General

  • Benign mesenchymal tumour.
  • Presentations: flank pain, hematuria, incidentaloma.[52]
    • Tumours >4 cm considered a risk for bleeding.[53]
  • AMLs occur may be elsewhere in the body, e.g. liver,[54] but are most common in the kidney.
  • In the PEComa group of tumours.

Epidemiology

  • May be associated with tuberous sclerosis -- 70% have an AML.
    • When compared to sporadic cases:
      • More often bilateral.
      • Usually bigger.
  • There is a suggestion that an epithelioid variant is more worisome.[55]
    • This is not confirmed by all studies.[56]

Microscopic

Features:

  • Smooth muscle.
  • Adipose tissue - not always present[57] - key feature.
  • Abundant blood vessels.

Epithelioid angiomyolipoma

Features:

  • Carcinoma-like morphology.
  • +/-Spindle cells.
  • "High grade" nuclei.
    • Pleomorphic nuclei.

DDx:

Images:

Cytologic

Features[57]

  • Nuclei - round/ovoid.
  • Chromatin - bland.

IHC

  • Melanocytic markers +ve.[59]
    • HMB-45 +ve in all cases (15/15).[60]
    • Melan A +ve in ~87% of cases (13/15).
  • Epithelial markers -ve.[59]
  • SMA +ve.
  • CD117 +ve/-ve.
  • Ki-67:[61]
    • Epithelioid variant of AML +ve.
    • Conventional AML -ve.

Mimics

Xanthogranulomatous pyelonephritis

  • Abbreviated XGP.
Main article: Xanthogranulomatous pyelonephritis

Malakoplakia

Main article: Malakoplakia

Rare stuffs

Juxtaglomerular cell tumour

  • AKA juxtaglomerular tumour, reninoma.[62]

General

  • Rare.
  • Etiology: increased renin.

Clinical:[62]

  • Hypertension.
  • Increased aldosterone.
    • Causes hypokalemia.
  • Increased plasma renin.

Microscopic

Features:[63]

  • Polygonal cells.
  • Abundant granular, eosinophilic cytoplasm.[64]
  • Perinuclear halo.

DDx:

Image:

Stains

Cytoplasmic granules.[64]

  • PAS +ve.
  • PASD +ve.

IHC

Features:[63]

  • Actin +ve.
  • Cytokeratin -ve.
  • HMB-45 -ve.

EM

Features:

  • Vesicles - contain renin.[65]

Renomedullary interstitial cell tumour

Main article: Renomedullary interstitial cell tumour

Metanephric adenoma

  • Should not be confused mesonephric adenoma, another term for nephrogenic adenoma.
    • Memory device: metanephric adenoma is a tumour.
Main article: Metanephric adenoma

Renal epithelial and stromal tumour

Abbreviated REST.

The lumping term for both:[67]

  1. Mixed epithelial and stromal tumour.
  2. Cystic nephroma.

Mixed epithelial and stromal tumour

  • Abbreviated MEST.

General

  • Rare - approx. 1.5% of renal neoplasms.[68]
  • Benign.
  • Prevalence: males > females.

Note:

  • Turbiner et al.[67] have suggested that cystic nephroma and mixed epithelial and stromal tumour (MEST) are one tumour.
    • The lumping term renal epithelial and stromal tumour, abbreviated REST.

Microscopic

Features:

  • Cysts lined by simple epithelium with hobnailing - key feature.
  • Stroma has an ovarian look:
    • Blue (basophilic).
    • Spindle cells.

Notes:

  • Parenchymal elements (e.g. glomueruli, tubules) are not found in the septa between the cysts.

Images

  • Cystic nephroma - low mag. (WC/Nephron)

  • Cystic nephroma - intermed. mag. (WC/Nephron)

IHC

Features:[68]

  • ER +ve.
  • PR +ve.
  • CD10 +ve.

DDx

  • Tubulocystic carcinoma.

Cystic nephroma

General

Gross

  • Bubble wrap-like appearance.

Image

  • Bubble wrap. (WC)

Microscopic

Features:

  • Cysts lined by simple epithelium with hobnailing - key feature.
  • Stroma has an ovarian look:
    • Blue (basophilic).
    • Spindle cells.

Notes:

  • Parenchymal elements (e.g. glomueruli, tubules) are not found in the septa between the cysts.

Images

  • Cystic nephroma - low mag. (WC/Nephron)

  • Cystic nephroma - intermed. mag. (WC/Nephron)

IHC

Features:

  • ER +ve.
  • PR +ve.
  • CD10 +ve.

Renal mucinous tubular and spindle cell carcinoma

  • AKA renal mucinous tubular spindle cell carcinoma.
  • AKA mucinous tubular and spindle cell carcinoma of the kidney.[69]
Main article: Renal mucinous tubular and spindle cell carcinoma

Collecting duct carcinoma

Main article: Collecting duct carcinoma

Renal medullary carcinoma

General

  • Rare.
  • Usually young adults.
  • Associated with sickle cell trait (heterozygotes for the sickle cell allele).[70]
  • Aggressive/poor prognosis.[71]

Aside:

Gross

Features:[71]

  • Well circumscribed.
  • Renal medulla.

Microscopic

Features:[70][71]

  • Variable architecture:
  • Desmoplastic stroma - prominent.
  • Inflammation:
    • Lymphocytes.
    • Neutrophils - margination in vessels.

DDx:

Image:

IHC

  • SMARCB1 (INI1) -ve.[72]

Tubulocystic carcinoma of the kidney

Main article: Tubulocystic carcinoma of the kidney

Acquired cystic disease-associated renal cell carcinoma

Main article: Acquired cystic disease-associated renal cell carcinoma

Pediatric

Main article: Pediatric kidney tumours

The most common is nephroblastoma (Wilms tumour).

Others include:

See also

References

  1. ↑ Humphrey, Peter A; Dehner, Louis P; Pfeifer, John D (2008). The Washington Manual of Surgical Pathology (1st ed.). Lippincott Williams & Wilkins. pp. 288. ISBN 978-0781765275.
  2. ↑ Zhou, Ming; Magi-Galluzzi, Cristina (2006). Genitourinary Pathology: A Volume in Foundations in Diagnostic Pathology Series (1st ed.). Churchill Livingstone. pp. 281-304. ISBN 978-0443066771.
  3. ↑ Srigley, JR.; Delahunt, B. (Jun 2009). "Uncommon and recently described renal carcinomas.". Mod Pathol 22 Suppl 2: S2-S23. doi:10.1038/modpathol.2009.70. PMID 19494850.
  4. ↑ Tickoo, SK.; Amin, MB. (Dec 1998). "Discriminant nuclear features of renal oncocytoma and chromophobe renal cell carcinoma. Analysis of their potential utility in the differential diagnosis.". Am J Clin Pathol 110 (6): 782-7. PMID 9844591.
  5. ↑ Humphrey, Peter A; Dehner, Louis P; Pfeifer, John D (2008). The Washington Manual of Surgical Pathology (1st ed.). Lippincott Williams & Wilkins. pp. 291. ISBN 978-0781765275.
  6. ↑ URL:http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001544/. Accessed on: 14 July 2011.
  7. ↑ 7.0 7.1 7.2 Humphrey, Peter A; Dehner, Louis P; Pfeifer, John D (2008). The Washington Manual of Surgical Pathology (1st ed.). Lippincott Williams & Wilkins. pp. 289. ISBN 978-0781765275.
  8. ↑ Schmid HP, Szabo J (May 1997). "[Renal cell carcinoma--a current review]" (in German). Praxis (Bern 1994) 86 (20): 837?3. PMID 9312811.
  9. ↑ 9.0 9.1 Cotran, Ramzi S.; Kumar, Vinay; Fausto, Nelson; Nelso Fausto; Robbins, Stanley L.; Abbas, Abul K. (2005). Robbins and Cotran pathologic basis of disease (7th ed.). St. Louis, Mo: Elsevier Saunders. pp. 1016. ISBN 0-7216-0187-1.
  10. ↑ Capitanio, U.; Cloutier, V.; Zini, L.; Isbarn, H.; Jeldres, C.; Shariat, SF.; Perrotte, P.; Antebi, E. et al. (Jun 2009). "A critical assessment of the prognostic value of clear cell, papillary and chromophobe histological subtypes in renal cell carcinoma: a population-based study.". BJU Int 103 (11): 1496-500. doi:10.1111/j.1464-410X.2008.08259.x. PMID 19076149.
  11. ↑ Delahunt, B.; Bethwaite, PB.; Nacey, JN. (Oct 2007). "Outcome prediction for renal cell carcinoma: evaluation of prognostic factors for tumours divided according to histological subtype.". Pathology 39 (5): 459-65. doi:10.1080/00313020701570061. PMID 17886093.
  12. ↑ 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.
  13. ↑ 13.0 13.1 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.
  14. ↑ 14.0 14.1 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.
  15. ↑ 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.
  16. ↑ 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.
  17. ↑ 17.0 17.1 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.
  18. ↑ 18.0 18.1 Memeo L, Jhang J, Assaad AM, et al. (February 2007). "Immunohistochemical analysis for cytokeratin 7, KIT, and PAX2: value in the differential diagnosis of chromophobe cell carcinoma". Am. J. Clin. Pathol. 127 (2): 225–9. doi:10.1309/9KWEA4W9Y94D1AEE. PMID 17210525. http://ajcp.ascpjournals.org/cgi/pmidlookup?view=long&pmid=17210525.
  19. ↑ Mazal PR, Exner M, Haitel A, et al. (January 2005). "Expression of kidney-specific cadherin distinguishes chromophobe renal cell carcinoma from renal oncocytoma". Hum. Pathol. 36 (1): 22–8. doi:10.1016/j.humpath.2004.09.011. PMID 15712178.
  20. ↑ 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.
  21. ↑ 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.
  22. ↑ 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.
  23. ↑ Kim MK, Kim S (December 2002). "Immunohistochemical profile of common epithelial neoplasms arising in the kidney". Appl. Immunohistochem. Mol. Morphol. 10 (4): 332–8. PMID 12613443.
  24. ↑ 24.0 24.1 de Peralta-Venturina, M.; Moch, H.; Amin, M.; Tamboli, P.; Hailemariam, S.; Mihatsch, M.; Javidan, J.; Stricker, H. et al. (Mar 2001). "Sarcomatoid differentiation in renal cell carcinoma: a study of 101 cases.". Am J Surg Pathol 25 (3): 275-84. PMID 11224597.
  25. ↑ 25.0 25.1 Lopez-Beltran, A.; Scarpelli, M.; Montironi, R.; Kirkali, Z. (May 2006). "2004 WHO classification of the renal tumors of the adults.". Eur Urol 49 (5): 798-805. doi:10.1016/j.eururo.2005.11.035. PMID 16442207.
  26. ↑ Cangiano, T.; Liao, J.; Naitoh, J.; Dorey, F.; Figlin, R.; Belldegrun, A. (Feb 1999). "Sarcomatoid renal cell carcinoma: biologic behavior, prognosis, and response to combined surgical resection and immunotherapy.". J Clin Oncol 17 (2): 523-8. PMID 10080595.
  27. ↑ 27.0 27.1 27.2 27.3 Dall'Oglio, MF.; Lieberknecht, M.; Gouveia, V.; Sant'Anna, AC.; Leite, KR.; Srougi, M.. "Sarcomatoid differentiation in renal cell carcinoma: prognostic implications.". Int Braz J Urol 31 (1): 10-6. PMID 15763002.
  28. ↑ Chapman-Fredricks, JR.; Herrera, L.; Bracho, J.; Gomez-Fernandez, C.; Leveillee, R.; Rey, L.; Jorda, M. (Oct 2011). "Adult renal cell carcinoma with rhabdoid morphology represents a neoplastic dedifferentiation analogous to sarcomatoid carcinoma.". Ann Diagn Pathol 15 (5): 333-7. doi:10.1016/j.anndiagpath.2011.03.002. PMID 21665507.
  29. ↑ Golshayan, AR.; George, S.; Heng, DY.; Elson, P.; Wood, LS.; Mekhail, TM.; Garcia, JA.; Aydin, H. et al. (Jan 2009). "Metastatic sarcomatoid renal cell carcinoma treated with vascular endothelial growth factor-targeted therapy.". J Clin Oncol 27 (2): 235-41. doi:10.1200/JCO.2008.18.0000. PMID 19064974.
  30. ↑ Chapman-Fredricks, JR.; Herrera, L.; Bracho, J.; Gomez-Fernandez, C.; Leveillee, R.; Rey, L.; Jorda, M. (Oct 2011). "Adult renal cell carcinoma with rhabdoid morphology represents a neoplastic dedifferentiation analogous to sarcomatoid carcinoma.". Ann Diagn Pathol 15 (5): 333-7. doi:10.1016/j.anndiagpath.2011.03.002. PMID 21665507.
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