Difference between revisions of "Renal tumor"

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==Presentations==
 
==Presentations==
−
Usually total nephrectomy.<ref name=stora>{{Stora utskärningen}}</ref>
+
Total or partial nephrectomy.
  
 
==Gross processing==
 
==Gross processing==
−
===Gross examination===
+
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/>
 
  
 
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
−
*Measure dimensions (and optionally the weight)
+
*Measure kidney dimensions (and optionally weight)
 
*Identify the surgical margin of the ureteral stump, renal vein and renal artery
 
*Identify the surgical margin of the ureteral stump, renal vein and renal artery
 
*In cases of a bulging tumor, apply ink to the surface of pericapsular fatty tissue by the tumor.
 
*In cases of a bulging tumor, apply ink to the surface of pericapsular fatty tissue by the tumor.
Line 20: Line 19:
 
*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 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===
−
===Gross reporting===
+
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.
 +
*Part of the fibrous capsule if being in contact with the tumor (oriented perpendicular to the capsular surface)
 +
*Margins of ureteral stump, renal vein and renal artery, and from hilus tissue (to detect possible tumor invasion of smaller blood vessels)
 +
*One slice of normal kidney tissue
 +
*Any detected lymph nodes in perihilar region
 +
*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.
  
−
*The appearance of the calyces and the papilla, possible changes in the renal pelvis, or the appearance of concretions
+
==Microscopic evaluation==
 +
Main components are:
 +
*Determining the histologic type
 +
*Staging
  
−
· In cases of tumor, the location and size of the tumor, macroscopic appearance of the incision surface, delimitation of surrounding structures, and relation to fibrous capsule and pericapsular tissue are indicated. If the fibrous capsule can be detached from the tumor surface, the inside of the capsule is examined where it rests against the tumor with regard to suspected tumor overgrowth or breakthrough
+
===Histologic type===
 +
Look for the most common tumors:
 +
<gallery mode=packed heights=210>
 +
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>
 +
{| 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
 +
|-
 +
! [[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]]
 +
|-
 +
! [[Papillary renal cell carcinoma]]
 +
| 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]]
 +
|-
 +
! Clear-cell papillary 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]]
 +
|-
 +
! Chromophobe renal cell carcinoma
 +
| 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]]
 +
|-
 +
! Renal cell carcinoma (unclassified/without further specification)
 +
| Contains features not fitting in subtypes. It includes sarcomatoid tumors without recognizable epithelial elements, mucin-producing tumors, and mixtures of epithelial and stromal elements. ||  ||
 +
|-
 +
! Oncocytoma
 +
| Small nests of cells, uniform small nuclei. || Ksp Cadherin, CD117, EMA, keratins || [[File:Histopathology of renal oncocytoma.jpg|190px]]
 +
|-
 +
! Angiomyolipoma
 +
| 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>
 +
|-
 +
! Multilocular cyst
 +
| 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> ||
 +
|-
 +
! Cystic nephroma
 +
| 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]]
 +
|-
 +
! Collecting duct carcinoma
 +
| Infiltrating high-grade adenocarcinoma centered in the medulla, desmoplastic stroma. || EMA, CK7, HMWCK, Pax2, Pax8
 +
|-
 +
! Microphthalmia Transcription Factor (MITF)- family translocation renal cell carcinoma
 +
| Clear and eosinophilic cells, voluminous cytoplasm, psammomatous calcifications (TFE3)<br>Biphasic tumors (TFEB). || HMB-45, Melan A, Cathepsin K, TFE3/TFEB
 +
|-
 +
! Fumarate hydratase-deficient renal cell carcinoma
 +
| Variable, intracystic papillary pattern with prominent hyalinization and usually tubulocystic patterns. || Loss of FH (deficient), 2SC
 +
|-
 +
! Succinate dehydrogenase-deficient renal cell carcinoma
 +
| Oncocytic cells with cytoplasmic vacuoles and inclusion-like spaces, neuroendocrine-like chromatin. || SDHB loss (deficient)
 +
|-
 +
! 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}} Last author update: 1 March 2018. Last staff update: 28 September 2022 (update in progress)}}</ref>
  
 +
===Staging===
 +
{{Renal tumor staging}}
  
 +
==Report==
 +
The report should include:
 +
*'''Histologic diagnosis'''
 +
*Greatest '''dimension''' (from grossing)
 +
*'''Grade'''
 +
*'''Radicality'''
  
−
 
+
Example:
 +
{|class=wikitable
 +
| Kidney, left, partial nephrectomy:
 +
*Clear cell renal cell carcinoma, 3.2 cm in greatest dimension, ISUP/WHO grade 3.
 +
*Surgical margins are negative for carcinoma.
 +
|}
  
−
Bits for microscopic examination:
+
Renal cell carcinomas should also have a synoptic report including:<ref name=stora/>
−
 
+
*Total or partial nephrectomy
−
· At least 3-4 pieces from the tumor, showing relationship to capsule, pericapsular tissue, surrounding kidney tissue, renal pelvis, hilus adipose tissue and blood vessels
+
*Tumor characteristics:
−
 
+
*In nephrectomy: Location  
−
· Particular pieces are taken from the part of the fibrous capsule that rests against the tumor (orientated directly to the canopy surface)
+
*Size
−
 
+
*Relationship to capsule, perinephric tissues, renal pelvis, adrenal gland and hilar blood vessels
−
· Particular pieces are taken from resection strips on the ureteral stump, renal vein and renal artery, and from hilus tissue (to examine possible tumor invasion of smaller blood vessels)
+
*Histological type
−
 
+
*Degree of differentiation
−
· A bit from normal kidney tissue
+
*Radicality
−
 
+
*Any lymph node metastases
−
· Pieces from any proven lymph nodes in hilus fat
+
{{Bottom}}
−
 
 
−
· A piece from macroscopically normal adrenal gland; in pathological changes, representative bits are taken
 
−
 
 
−
· In kidney pelvic cancer, at least three pieces are taken from the macroscopically tumor-suspected area, including borderline to normal mucosa, and adjacent peripelvic fatty tissue. Take about 1 piece per cm2 from other parts of the renal pelvis, as well as a piece from the resection border on the ureteral stump. In case of changes in the ureteral stump, take pieces from these as well
 
−
 
 
−
· In transplant cases, the entire hilus region for histology is taken, with parallel vessels including all vessels. From the parenchyma, pieces are taken from necrosis, bleeding and other aberrant cures, as well as 2-3 pieces from macroscopically normal parts.
 
−
 
 
−
Partial nephrectomy (usually due to tumor):
 
−
 
 
−
· Paint the resection surface with ink
 
−
 
 
−
· Take pieces perpendicular to the resection surface to assess the radicality
 
−
 
 
−
 
 
−
 
 
−
The answer should include information on:
 
−
 
 
−
· Type of operation / preparation
 
−
 
 
−
In tumor:
 
−
 
 
−
· Tumor size
 
−
 
 
−
· Location
 
−
 
 
−
· Relationship to capsule, pericapsular tissue, renal pelvis, adrenal gland, hilus blood vessels
 
−
 
 
−
· Histological type, degree of differentiation
 
−
 
 
−
· Radicalism
 
−
 
 
−
· Metastases, possibly lymph nodes present
 
−
 
 
−
· Pathological changes in general
 
−
 
 
−
 
 
−
 
 
−
For non-neoplastic changes:
 
−
 
 
−
· Type of change
 
−
 
 
−
· Location / distribution
 
−
 
 
−
· Degree / intensity
 
−
-->
 
−
 
 
−
https://www.dovepress.com/unclassified-renal-cell-carcinoma-diagnostic-difficulties-and-treatmen-peer-reviewed-fulltext-article-RRU
 
−
 
 
−
https://www.dovepress.com/cr_data/article_fulltext/s154000/154932/img/rru_154932_T001.jpg
 

Revision as of 14:31, 5 January 2023

Author: Mikael Häggström [note 1]

Presentations

Total or partial nephrectomy.

Gross processing

For orientation, the ureter stump points to the inferior pole.[1]

Components:[1]

  • Note the appearance of the renal surface
  • Inspect the capsule and pericapsular soft tissue, and possibly an accompanying adrenal gland
  • Measure kidney dimensions (and optionally weight)
  • Identify the surgical margin of the ureteral stump, renal vein and renal artery
  • In cases of a bulging tumor, apply ink to the surface of pericapsular fatty tissue by the tumor.
  • 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.
  • Note and possibly measure the medullary thickness and the width of the renal pelvis
  • 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.

Slices for submission

Including:[1]

  • 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)
  • Margins of ureteral stump, renal vein and renal artery, and from hilus tissue (to detect possible tumor invasion of smaller blood vessels)
  • One slice of normal kidney tissue
  • Any detected lymph nodes in perihilar region
  • 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 cm2 from other parts of the renal pelvis, as well as a piece from the surgical edge of the ureteral stump.

Microscopic evaluation

Main components are:

  • Determining the histologic type
  • Staging

Histologic type

Look for the most common tumors:

  • Renal tumors by relative incidence and prognosis.png

  • Renal cell carcinomas frequently display hemosiderin and small cytoplasmic vacuoles as shown.[2]

Renal carcinoma subtype Characteristic morphology[3] Positive immunohistochemistry[3] Image
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) Histopathology of renal clear cell carcinoma.jpg
Papillary renal cell carcinoma Papillary architecture, small-to-medium-sized cells. Often foamy macrophages in fibrovascular cores. Vimentin, keratins, CK7, AMACR, RCC Histopathology of papillary renal cell carcinoma type 1.jpg
Clear-cell papillary renal cell carcinoma Clear cells in papillary, solid, or nested pattern, abluminal linear arrangement of nuclei. CA-IX (basolateral membranous), HMWCK Histopathology of clear cell papillary renal cell carcinoma.jpg
Chromophobe renal cell carcinoma Distinct (vegetable-like) cell borders, raisin-like nuclei with perinuclear halos. Ksp Cadherin, CD117, EMA, keratins, CK7 Histopathology of classic chromophobe renal cell carcinoma with pale cells.jpg
Renal cell carcinoma (unclassified/without further specification) Contains features not fitting in subtypes. It includes sarcomatoid tumors without recognizable epithelial elements, mucin-producing tumors, and mixtures of epithelial and stromal elements.
Oncocytoma Small nests of cells, uniform small nuclei. Ksp Cadherin, CD117, EMA, keratins Histopathology of renal oncocytoma.jpg
Angiomyolipoma 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%)[4]
Multilocular cyst Encapsulated, non-infiltrating and composed of non-comumnicating cysts filled with clear, straw-colored, or blood-tinged fluid.[5]
Cystic nephroma Cysts lined by simple epithelium with "hobnail morphology", that is, the nuclei of the epithelium bulges into the lumen of the cysts.
Ovarian-like stroma with pindle cell morphology and basophilic cytoplasm.		 Histopathology of cystic nephroma.jpg
Collecting duct carcinoma Infiltrating high-grade adenocarcinoma centered in the medulla, desmoplastic stroma. EMA, CK7, HMWCK, Pax2, Pax8
Microphthalmia Transcription Factor (MITF)- family translocation renal cell carcinoma Clear and eosinophilic cells, voluminous cytoplasm, psammomatous calcifications (TFE3)
Biphasic tumors (TFEB).		 HMB-45, Melan A, Cathepsin K, TFE3/TFEB
Fumarate hydratase-deficient renal cell carcinoma Variable, intracystic papillary pattern with prominent hyalinization and usually tubulocystic patterns. Loss of FH (deficient), 2SC
Succinate dehydrogenase-deficient renal cell carcinoma Oncocytic cells with cytoplasmic vacuoles and inclusion-like spaces, neuroendocrine-like chromatin. SDHB loss (deficient)
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).[6]

Staging

By AJCC 8th edition:[7][8] edit

Stage TNM Description
Tx, N0, M0 Tumor cannot be assessed
T0, N0, M0 No evidence of primary tumor
I T1, N0, M0 Tumor ≤7 cm; limited to kidney
T1a, N0, M0 Tumor ≤4 cm; limited to kidney
T1b, N0, M0 Tumor 4-≤7 cm; limited to kidney
II T2, N0, M0 Tumor >7 cm; limited to kidney
T2a, N0, M0 Tumor 7-≤10 cm; limited to kidney
T2b, N0, M0 Tumor >10 cm; limited to kidney
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).
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.

Report

The report should include:

  • Histologic diagnosis
  • Greatest dimension (from grossing)
  • Grade
  • Radicality

Example:

Kidney, left, partial nephrectomy:
  • Clear cell renal cell carcinoma, 3.2 cm in greatest dimension, ISUP/WHO grade 3.
  • Surgical margins are negative for carcinoma.

Renal cell carcinomas should also have a synoptic report including:[1]

  • Total or partial nephrectomy
  • Tumor characteristics:
  • In nephrectomy: Location
  • Size
  • Relationship to capsule, perinephric tissues, renal pelvis, adrenal gland and hilar blood vessels
  • Histological type
  • Degree of differentiation
  • Radicality
  • Any lymph node metastases

Notes

  1. ↑ For a full list of contributors, see article history. Creators of images are attributed at the image description pages, seen by clicking on the images. See Patholines:Authorship for details.

Main page

References

  1. ↑ 1.0 1.1 1.2 1.3 Monica Dahlgren, Janne Malina, Anna Måsbäck, Otto Ljungberg. Stora utskärningen. KVAST (Swedish Society of Pathology). Retrieved on 2019-09-26.
  2. ↑ . Kidney tumor - Adult renal cell carcinoma - common - Renal cell carcinoma overview. PathologyOutlines. Topic Completed: 1 April 2017. Minor changes: 15 May 2021
  3. ↑ 3.0 3.1 Unless otherwise specified, reference in table is: Sirohi, Deepika; Smith, Steven C.; Agarwal, Neeraj; Maughan, Benjamin L. (2018). "Unclassified renal cell carcinoma: diagnostic difficulties and treatment modalities ". Research and Reports in Urology Volume 10: 205–217. doi:10.2147/RRU.S154932. ISSN 2253-2447. 
  4. ↑ Esheba, Ghada El Sayed; Esheba, Noha El Sayed (2013). "Angiomyolipoma of the kidney: Clinicopathological and immunohistochemical study ". Journal of the Egyptian National Cancer Institute 25 (3): 125–134. doi:10.1016/j.jnci.2013.05.002. ISSN 11100362. 
  5. ↑ Banner, MP; Pollack, HM; Chatten, J; Witzleben, C (1981). "Multilocular renal cysts: radiologic-pathologic correlation ". American Journal of Roentgenology 136 (2): 239–247. doi:10.2214/ajr.136.2.239. ISSN 0361-803X. 
  6. ↑ Error on call to Template:cite web: Parameters url and title must be specifiedNicole K. Andeen, M.D., Maria Tretiakova, M.D., Ph.D.. . Pathology Outlines. Last author update: 1 March 2018. Last staff update: 28 September 2022 (update in progress)}}
  7. ↑ . Kidney Cancer Stages. cancer.org. Last Revised: February 1, 2020
  8. ↑ Swami, Umang; Nussenzveig, Roberto H.; Haaland, Benjamin; Agarwal, Neeraj (2019). "Revisiting AJCC TNM staging for renal cell carcinoma: quest for improvement ". Annals of Translational Medicine 7 (S1): S18–S18. doi:10.21037/atm.2019.01.50. ISSN 23055839. 

Image sources


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