Renal tumor: Difference between revisions

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==Gross processing==
==Gross processing==
For orientation, the ureter stump points to the inferior pole.<ref name=stora>{{Stora utskärningen}}</ref>
For orientation, the ureter stump points to the inferior pole.<ref name="stora">{{Stora utskärningen}}</ref>
 
Components:<ref name="stora" />


Components:<ref name=stora/>
*Note the appearance of the renal surface
*Note the appearance of the renal surface
*Inspect the capsule and pericapsular soft tissue, and possibly an accompanying adrenal gland
*Inspect the capsule and pericapsular soft tissue, and possibly an accompanying adrenal gland
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*Dissect the ureteral stump
*Dissect the ureteral stump
*Split the kidney in the middle, in the coronal plane. Release the fibrous capsule. Dissect the renal pelvis and calyces. Inspect the parenchyma on cut surfaces.
*Split the kidney in the middle, in the coronal plane. Release the fibrous capsule. Dissect the renal pelvis and calyces. Inspect the parenchyma on cut surfaces.
:*Note and possibly measure the medullary thickness and the width of the renal pelvis
:*Note and possibly measure the medullary thickness and the width of the renal pelvis
:*Note the appearance of any concretions
:*Note the appearance of any concretions
*Note the location and size of the tumor, macroscopic appearance of cut surfaces, delimitation compared to surrounding structures, and relation to the fibrous capsule and perinephric tissues. If the fibrous capsule can be detached from the tumor surface, the inside of the capsule is examined where it was in contact with tumor, in order to detect any tumor overgrowth or breakthrough.
*Note the location and size of the tumor, macroscopic appearance of cut surfaces, delimitation compared to surrounding structures, and relation to the fibrous capsule and perinephric tissues. If the fibrous capsule can be detached from the tumor surface, the inside of the capsule is examined where it was in contact with tumor, in order to detect any tumor overgrowth or breakthrough.


===Slices for submission===
===Slices for submission===
Including:<ref name=stora/>
Including:<ref name="stora" />
 
*At least 3-4 pieces from the tumor, showing relationship to surrounding kidney tissue, renal capsule, perinephric tissues, renal pelvis, hilar adipose tissue and blood vessels.
*At least 3-4 pieces from the tumor, showing relationship to surrounding kidney tissue, renal capsule, perinephric tissues, renal pelvis, hilar adipose tissue and blood vessels.
*Part of the fibrous capsule if being in contact with the tumor (oriented perpendicular to the capsular surface)
*Part of the fibrous capsule if being in contact with the tumor (oriented perpendicular to the capsular surface)
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*One slice of normal kidney tissue
*One slice of normal kidney tissue
*Any detected lymph nodes in perihilar region
*Any detected lymph nodes in perihilar region
*At least one slice from any included adrenal gland.  
*At least one slice from any included adrenal gland.
*In case of cancer in the renal pelvis, at least three slices from the tumor-suspected area, including radicality slices from surrounding normal mucosa, and adjacent peripelvic fatty tissue. Take about 1 piece per cm<sup>2</sup> from other parts of the renal pelvis, as well as a piece from the surgical edge of the ureteral stump.  
*In case of cancer in the renal pelvis, at least three slices from the tumor-suspected area, including radicality slices from surrounding normal mucosa, and adjacent peripelvic fatty tissue. Take about 1 piece per cm<sup>2</sup> from other parts of the renal pelvis, as well as a piece from the surgical edge of the ureteral stump.


==Microscopic evaluation==
==Microscopic evaluation==
Main components are:
Main components are:
*Determining the histologic type
*Determining the histologic type
*Staging
*Staging
Line 39: Line 44:
===Histologic type===
===Histologic type===
Look for the most common tumors:
Look for the most common tumors:
<gallery mode=packed heights=210>
<gallery mode="packed" heights="210">
File:Renal tumors by relative incidence and prognosis.png
File:Renal tumors by relative incidence and prognosis.png
File:Histopathology of papillary renal cell carcinoma with ample hemosiderin.jpg|'''Renal cell carcinomas''' frequently display hemosiderin and small cytoplasmic vacuoles as shown.<ref>{{cite web|url=https://www.pathologyoutlines.com/topic/kidneytumormalignantrcc.html|title=Kidney tumor - Adult renal cell carcinoma - common - Renal cell carcinoma overview|website=PathologyOutlines}} Topic Completed: 1 April 2017. Minor changes: 15 May 2021</ref>
</gallery>
</gallery>
{| class="wikitable"
{| class="wikitable"
! Renal carcinoma subtype !! Characteristic morphology<ref name="SirohiSmith2018">Unless otherwise specified, reference in table is: {{cite journal|last1=Sirohi|first1=Deepika|last2=Smith|first2=Steven C.|last3=Agarwal|first3=Neeraj|last4=Maughan|first4=Benjamin L.|title=Unclassified renal cell carcinoma: diagnostic difficulties and treatment modalities|journal=Research and Reports in Urology|volume=Volume 10|year=2018|pages=205–217|issn=2253-2447|doi=10.2147/RRU.S154932}}</ref> !! Positive immunohistochemistry<ref name="SirohiSmith2018"/> !! Image
!Renal carcinoma subtype!!Characteristic morphology<ref name="SirohiSmith2018">Unless otherwise specified, reference in table is: {{cite journal|last1=Sirohi|first1=Deepika|last2=Smith|first2=Steven C.|last3=Agarwal|first3=Neeraj|last4=Maughan|first4=Benjamin L.|title=Unclassified renal cell carcinoma: diagnostic difficulties and treatment modalities|journal=Research and Reports in Urology|volume=Volume 10|year=2018|pages=205–217|issn=2253-2447|doi=10.2147/RRU.S154932}}</ref>!!Positive immunohistochemistry<ref name="SirohiSmith2018" />!!Image
|-
|-
! [[Clear cell renal cell carcinoma]]
![[Clear cell renal cell carcinoma]]
| Clear cells in nests or solid pattern, delicate branching fibrovascular network. || Vimentin, EMA, keratin, CD10, Pax2, RCC, CAIX (circumferential membranous) || [[File:Histopathology of renal clear cell carcinoma.jpg|190px]]
|Clear cells in nests or solid pattern, delicate branching fibrovascular network.||Vimentin, EMA, keratin, CD10, Pax2, RCC, CAIX (circumferential membranous)||[[File:Histopathology of renal clear cell carcinoma.jpg|190px]]
|-
|-
! Papillary renal cell carcinoma, type 1
![[Papillary renal cell carcinoma]]
| Papillary architecture, small-to-medium-sized cells, foamy macrophages in fibrovascular cores. || Vimentin, keratins, CK7, AMACR, RCC || [[File:Histopathology of papillary renal cell carcinoma type 1.jpg|190px]]
|Papillary architecture, small-to-medium-sized cells. Often foamy macrophages in fibrovascular cores.||Vimentin, keratins, CK7, AMACR, RCC||[[File:Histopathology of papillary renal cell carcinoma type 1.jpg|190px]]
|-
|-
! Papillary renal cell carcinoma, type 2
!Clear-cell papillary renal cell carcinoma
| Papillary architecture, medium to large cell, pseudostratified nuclei. || Variable || [[File:Histopathology of papillary renal cell carcinoma type 2.jpg|190px]]
|Clear cells in papillary, solid, or nested pattern, abluminal linear arrangement of nuclei.||CA-IX (basolateral membranous), HMWCK||[[File:Histopathology of clear cell papillary renal cell carcinoma.jpg|190px]]
|-
|-
! Clear-cell papillary renal cell carcinoma  
!Chromophobe renal cell carcinoma
| Clear cells in papillary, solid, or nested pattern, abluminal linear arrangement of nuclei. || CA-IX (basolateral membranous), HMWCK || [[File:Histopathology of clear cell papillary renal cell carcinoma.jpg|190px]]
|Distinct (vegetable-like) cell borders, raisin-like nuclei with perinuclear halos.||Ksp Cadherin, CD117, EMA, keratins, CK7||[[File:Histopathology of chromophobe renal cell carcinoma.png|190px]]
|-
|-
! Chromophobe renal cell carcinoma  
!Renal cell carcinoma (unclassified/without further specification)
| Distinct (vegetable-like) cell borders, raisin-like nuclei with perinuclear halos. || Ksp Cadherin, CD117, EMA, keratins, CK7 || [[File:Histopathology of classic chromophobe renal cell carcinoma with pale cells.jpg|190px]]
|Contains features not fitting in subtypes. It includes sarcomatoid tumors without recognizable epithelial elements, mucin-producing tumors, and mixtures of epithelial and stromal elements.|| ||
|-
|-
! Renal cell carcinoma (unclassified/without further specification)
!Oncocytoma
| Contains features not fitting in subtypes. It includes sarcomatoid tumors without recognizable epithelial elements, mucin-producing tumors, and mixtures of epithelial and stromal elements. ||  ||
|Small nests of cells, uniform small nuclei.||Ksp Cadherin, CD117, EMA, keratins||[[File:Histopathology of renal oncocytoma.jpg|190px]]
|-
|-
! Oncocytoma
!Angiomyolipoma
| Small nests of cells, uniform small nuclei. || Ksp Cadherin, CD117, EMA, keratins || [[File:Histopathology of renal oncocytoma.jpg|190px]]
|Classically triphasic with myoid spindle cells, mature adipose tissue (seen in > 90% tumors) and dysmorphic thick walled blood vessels without elastic lamina.||HMB-45 (100%), Melan-A (87%) SMA (73%)<ref name="EshebaEsheba2013">{{cite journal|last1=Esheba|first1=Ghada El Sayed|last2=Esheba|first2=Noha El Sayed|title=Angiomyolipoma of the kidney: Clinicopathological and immunohistochemical study|journal=Journal of the Egyptian National Cancer Institute|volume=25|issue=3|year=2013|pages=125–134|issn=11100362|doi=10.1016/j.jnci.2013.05.002}}</ref>
|-
|-
! Angiomyolipoma
!Multilocular cyst
| Classically triphasic with myoid spindle cells, mature adipose tissue (seen in > 90% tumors) and dysmorphic thick walled blood vessels without elastic lamina. || HMB-45 (100%), Melan-A (87%) SMA (73%)<ref name="EshebaEsheba2013">{{cite journal|last1=Esheba|first1=Ghada El Sayed|last2=Esheba|first2=Noha El Sayed|title=Angiomyolipoma of the kidney: Clinicopathological and immunohistochemical study|journal=Journal of the Egyptian National Cancer Institute|volume=25|issue=3|year=2013|pages=125–134|issn=11100362|doi=10.1016/j.jnci.2013.05.002}}</ref>
|Encapsulated, non-infiltrating and composed of non-comumnicating cysts filled with clear, straw-colored, or blood-tinged fluid.<ref name="BannerPollack1981">{{cite journal|last1=Banner|first1=MP|last2=Pollack|first2=HM|last3=Chatten|first3=J|last4=Witzleben|first4=C|title=Multilocular renal cysts: radiologic-pathologic correlation|journal=American Journal of Roentgenology|volume=136|issue=2|year=1981|pages=239–247|issn=0361-803X|doi=10.2214/ajr.136.2.239}}</ref>||
|-
|-
! Multilocular cyst
!Cystic nephroma
| Encapsulated, non-infiltrating and composed of non-comumnicating cysts filled with clear, straw-colored, or blood-tinged fluid.<ref name="BannerPollack1981">{{cite journal|last1=Banner|first1=MP|last2=Pollack|first2=HM|last3=Chatten|first3=J|last4=Witzleben|first4=C|title=Multilocular renal cysts: radiologic-pathologic correlation|journal=American Journal of Roentgenology|volume=136|issue=2|year=1981|pages=239–247|issn=0361-803X|doi=10.2214/ajr.136.2.239}}</ref> ||  
|Cysts lined by simple epithelium with "hobnail morphology", that is, the nuclei of the epithelium bulges into the lumen of the cysts.<br>Ovarian-like stroma with pindle cell morphology and basophilic cytoplasm.|| ||[[File:Histopathology of cystic nephroma.jpg|190px]]
|-
|-
! Cystic nephroma
!Collecting duct carcinoma
| Cysts lined by simple epithelium with "hobnail morphology", that is, the nuclei of the epithelium bulges into the lumen of the cysts.<br>Ovarian-like stroma with pindle cell morphology and basophilic cytoplasm. || || [[File:Histopathology of cystic nephroma.jpg|190px]]
|Infiltrating high-grade adenocarcinoma centered in the medulla, desmoplastic stroma.||EMA, CK7, HMWCK, Pax2, Pax8
|-
|-
! Collecting duct carcinoma  
!Microphthalmia Transcription Factor (MITF)- family translocation renal cell carcinoma
| Infiltrating high-grade adenocarcinoma centered in the medulla, desmoplastic stroma. || EMA, CK7, HMWCK, Pax2, Pax8
|Clear and eosinophilic cells, voluminous cytoplasm, psammomatous calcifications (TFE3)<br>Biphasic tumors (TFEB).||HMB-45, Melan A, Cathepsin K, TFE3/TFEB
|-
|-
! Microphthalmia Transcription Factor (MITF)- family translocation renal cell carcinoma  
!Fumarate hydratase-deficient renal cell carcinoma
| Clear and eosinophilic cells, voluminous cytoplasm, psammomatous calcifications (TFE3)<br>Biphasic tumors (TFEB). || HMB-45, Melan A, Cathepsin K, TFE3/TFEB
|Variable, intracystic papillary pattern with prominent hyalinization and usually tubulocystic patterns.||Loss of FH (deficient), 2SC
|-
|-
! Fumarate hydratase-deficient renal cell carcinoma  
!Succinate dehydrogenase-deficient renal cell carcinoma
| Variable, intracystic papillary pattern with prominent hyalinization and usually tubulocystic patterns. || Loss of FH (deficient), 2SC
|Oncocytic cells with cytoplasmic vacuoles and inclusion-like spaces, neuroendocrine-like chromatin.||SDHB loss (deficient)
|-
|-
! Succinate dehydrogenase-deficient renal cell carcinoma
!Renal medullary carcinoma
| Oncocytic cells with cytoplasmic vacuoles and inclusion-like spaces, neuroendocrine-like chromatin. || SDHB loss (deficient)
|High-grade adenocarcinoma, inflammatory, myxoid, or desmoplastic stroma, evidence of sickle cell disease/trait.||INI-I loss, Oct 3/4 positive
|-
! Renal medullary carcinoma  
| High-grade adenocarcinoma, inflammatory, myxoid, or desmoplastic stroma, evidence of sickle cell disease/trait. || INI-I loss, Oct 3/4 positive
|}
|}
 
'''Multifocality''' of tumors favors mainly [[papillary renal cell carcinoma]] (although most of these are unifocal).<ref>{{cite web|papillary renal cell carcinoma is more often bilateral and multifocal compared|title=Kidney tumor - Papillary|author=Nicole K. Andeen, M.D., Maria Tretiakova, M.D., Ph.D.|website=Pathology Outlines}}<nowiki> Last author update: 1 March 2018. Last staff update: 28 September 2022 (update in progress)}}</nowiki></ref>
===Staging===
{| class="wikitable" align="center"
By AJCC 8th edition:<ref>{{cite web|url=https://www.cancer.org/cancer/kidney-cancer/detection-diagnosis-staging/staging.html|title=Kidney Cancer Stages|website=cancer.org}} Last Revised: February 1, 2020</ref><ref name="SwamiNussenzveig2019">{{cite journal|last1=Swami|first1=Umang|last2=Nussenzveig|first2=Roberto H. |last3=Haaland|first3=Benjamin |last4=Agarwal|first4=Neeraj |title=Revisiting AJCC TNM staging for renal cell carcinoma: quest for improvement|journal=Annals of Translational Medicine|volume=7|issue=S1|year=2019|pages=S18–S18|issn=23055839|doi=10.21037/atm.2019.01.50}}</ref>
|+Immunohistochemistry distinction between renal cell carcinoma types<ref>{{cite web|url=https://www.us.elsevierhealth.com/immunoquery.html|title=Immunoquery|accessdate=2023-05-17}}</ref>
{| class="wikitable"
! Stage !! TNM !! Description
|-
|rowspan=2|
|'''Tx''', N0, M0
|Tumor cannot be assessed
|-
|'''T0''', N0, M0
|No evidence of primary tumor
|-
|-
|rowspan=3|I
!Renal cell  carcinoma type
|'''T1''', N0, M0
!RCC
|Tumor ≤7&nbsp;cm; limited to kidney
!CK7
!CAIX
|-
|-
|'''T1a''', N0, M0
!Clear cell
|Tumor ≤4&nbsp;cm; limited to kidney
|'''62%'''
|16%
|'''86% (box-like)'''
|-
|-
|'''T1b''', N0, M0
!Clear cell  papillary
|Tumor 4-≤7&nbsp;cm; limited to kidney
|18%
|'''94%'''
|'''97% (cup-like)'''
|-
|-
|rowspan=3|II
!Papillary
|'''T2''', N0, M0
|'''81%'''
|Tumor >7&nbsp;cm; limited to kidney
|'''74%'''
|'''61%'''
|-
|-
|'''T2a''', N0, M0
!Chromophobe
|Tumor 7-≤10&nbsp;cm; limited to kidney
|6%
|-
|'''89%'''
|'''T2b''', N0, M0
|22%
|Tumor >10&nbsp;cm; limited to kidney
|-
|rowspan=5|III
|'''T3''', N0, M0
|Tumor extends to major veins or perinephric tissue but not into ipsilateral adrenal gland nor beyond Gerota's fascia
|-
|'''T3a''', N0, M0
|Tumor grossly extends into renal vein or its segmental branches, or tumor invades the pelvicalyceal system, or tumor invades perirenal and/or renal sinus fat but not beyond Gerota's fascia
|-
|'''T3b''', N0, M0
|Tumor grossly extends into vena cava below the diaphragm
|-
|'''T3c''', N0, M0
|Tumor grossly extends into vena cava above the diaphragm or invades the wall of the vena cava
|-
| '''T1-T3, N1''', M0
| The main tumor can be any size and may be outside the kidney, but it has not spread beyond Gerota’s fascia. The cancer has spread to regional lymph nodes (N1) but has not spread to distant lymph nodes or other organs (M0).
|-
|rowspan=2| IV
|'''T4''', any N, M0
| Tumor invades beyond Gerota's fascia
|-
| Any T, any N, '''M1'''
| Tumor has spread to distant lymph nodes and/or other organs.
|}
|}
===Staging===
{{Renal tumor staging}}


==Report==
==Report==
There should preferably be a free text report and a synoptic report, the free text report including:
The report should include:
 
*'''Histologic diagnosis'''
*'''Histologic diagnosis'''
*Greatest '''dimension''' (from grossing)
*Greatest '''dimension''' (from grossing)
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Example:
Example:
{|class=wikitable
{| class="wikitable"
| Kidney, left, partial nephrectomy:
|Kidney, left, partial nephrectomy:
 
*Clear cell renal cell carcinoma, 3.2 cm in greatest dimension, ISUP/WHO grade 3.
*Clear cell renal cell carcinoma, 3.2 cm in greatest dimension, ISUP/WHO grade 3.
*Surgical margins are negative for carcinoma.
*Surgical margins are negative for carcinoma.
|}
|}


The synoptic report should include:<ref name=stora/>
Renal cell carcinomas should also have a synoptic report including:<ref name="stora" />
 
*Total or partial nephrectomy
*Total or partial nephrectomy
*Tumor characteristics:
*Tumor characteristics:
*In nephrectomy: Location  
*In nephrectomy: Location
*Size
*Size
*Relationship to capsule, perinephric tissues, renal pelvis, adrenal gland and hilar blood vessels
*Relationship to capsule, perinephric tissues, renal pelvis, adrenal gland and hilar blood vessels
Retrieved from "https://patholines.org/Renal_tumor"