renal anatomy ,epidemology of renal cancer histology of renal tumors clinical presentation radiology of renal tumors

1. KIDNEY & RENAL PELVIS
Presented by: Dr. Isha Jaiswal
Moderator: Dr. Madhup Rastogi
Date:20th august 2014
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2. KIDNEY : location
• pair of organs located in the abdominal cavity
on either side of the spine in a retroperitoneal
position.
• Approx. at vertebral level T12 to L3,
• right kidney being slightly lower than the left.
• Left kidney is little nearer to median plane than
right
• Long axis of kidney is directed downward and
laterally &runs parallel to the lateral margin of
the psoas muscle
• The kidneys are mobile organs that move
vertically within the retroperitoneum on
average 0.9 cm to 1.3 cm and as much as 4 cm
during normal respiration
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3. KIDNEYS :external features
• Shape :Bean shaped
• poles: upper & lower
• Border: medial & lateral
• Surface: anterior & posterior
• Size: approx. 11–14 cm in length, 6 cm wide and 3cm thick
• Weight: around 150 gm. in males & 135 gm. in females

4. External Features
• Hilum of the kidney,
• Concave medial border of
the kidney
• Structures enter / leave
through the hilum (from
anterior to posterior),
» Renal vein
» Renal artery
» Pelvis
» Ureter
» Renal nerves
» Lymphatics.

5. Relations of kidney
 Upper pole: adrenal gland
 Lower pole: about 2.5 cm above iliac creast
 Posterior relations:
 Diaphragm
 Muscles: psoas major,
quadratus lumborum,
transv.abdominis
 Ribs: 11th &12th ribs on left ,
only 12th on right side
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6. Anterior relations Right kidney:
 Rt. adrenal gland
 Liver
 2nd part duodenum
 Hepatic flexure colon
 jejunum
Left kidney
 Lt. adrenal gland
 Spleen
 Stomach
 Pancreas
 splenic flexure colon
 jejunum
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7. Coverings of kidney
 fibrous tissue, the
renal capsule,
 perinephric fat,
 renal fascia (of
Gerota)
 paranephric fat.
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8. Internal features
parenchyma, of the kidney is
divided into two major
structures:
Renal cortex: lobules & column
medulla: pyramid,papilla,calyx

9. Functional unit of kidney: nephron
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10. 10

11. URINARY DRAINAGE
Pyramids
Papillae
Minor calyces
Major calyces
Renal pelvis

12. Blood supply of
kidney
Arterial supply:
renal artery
Venous drainage:
renal vein

13. • Lymph Drainage :
• Nerve Supply:
• Through sympathetic plexus (T10 – L1) fibres
• Afferent nerves T10 to T12 thoracic nerves.
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The right kidney drains predominantly
into the paracaval and interaortocaval
lymph nodes
left kidney drains exclusively to the
para-aortic lymph nodes

14. CANCERS OF KIDNEY
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15. Renal Tumors: incidence
In U.S in 2011 (ref:parez)
• 60,920 cases diagnosed(4 % of all new cancers)
• 13,120 deaths (2% of cancer related death)
• Approx 88% of solid renal masses are malignant
• RCC comprise 80-85%of primary kidney tumors
• Transitional cell carcinoma acoount for 7 % of kidney tumors
• Rest are lymphoma, sarcomas, oncocytoma
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16. Renal Cell Carcinoma
• First described by Konig in 1826.
• In 1883 Grawitz, noted the fatty content of cancer cells similar to that of
adrenal cells. (Also called as Grawitz’s tumor)
• All these tumors arise from Renal proximal tubular epithelium
• The incidence of RCC is increasing & the size decreasing because of
increased use of abdominal CT scans
• Male predominance (1.6:1.0 M:F)
• Highest incidence between age 50-70
-Median age of diagnosis is 66 years
-Median age of death 70 years
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17. Risk Factors
• Tobacco smoking
contributes to 24-30% of RCC cases
Tobacco results in a 2-fold increased risk
• Environmental:
Cadmium, thorium-di-oxide,
petroleum
aresenic
phenacetin analgesics.
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18. • Occupational:
leather tanners, shoe workers, asbestos workers, petroleum,
blast furnace, iron & steel industry
• Hormonal: diethylistillbestrol,
• Dietary: fried meats,(vegetables, fruits & alcohol are protective)
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19. • Obesity,
• HTN,
• DM
• ACKD:
• 50% Pt. on long term dialysis(>3 yrs)
develop Acquired polycystic kidney disease, out of which 5.8% develops RCC
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20. RCC variant
It is made up of no. of different types of cancers with different histology, different
clinical courses and caused by different gene.
A sarcomatoid variant represents1% to 6% of renal cell carcinoma and these tumors are
associated with a significantly poorer prognosis.
BHD=Birt-Hogg-Dubé; FH=fumarate hydratase; VHL=von Hippel-Lindau.
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Clear cell
75%
Type
Incidence (%)
Associated
mutations
VHL
Papillary type 1
5%
c-Met
Papillary type 2
10%
FH
Chromophobe
5%
BHD
Oncocytoma
5%
BHD

21. Hereditary Renal Cancer Syndromes
Syndrome Chromosome
Location (Gene)
Renal
Manifestations
Other Manifestations
Von Hippel-
Lindau (VHL)
3p25
VHL
Clear cell renal
carcinoma: solid
and/or cystic,
multiple and
bilateral
28%-45%
Retinal and central nervous system
hemangioblastomas; pheochromocytomas;
pancreatic cysts and neuroendocrine
tumors; endolymphatic sac tumors;
epididymal and broad ligament
cystadenomas
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22. Syndrome Chromosome
Location (Gene)
Renal Manifestations Other Manifestations
Hereditary papillary renal
carcinoma type1(HPRC)
7q31
MET
Papillary renal carcinoma type
1: solid, multiple and bilateral
None
Hereditary
leiomyomatosis and renal
cell carcinoma (HLRCC)
1q42-43
FH
Papillary renal carcinoma type
2, collecting duct carcinoma:
solitary, aggressive
Uterine leiomyomas and
leiomyosarcomas;
cutaneous leiomyomas
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23. Syndrome Chromosome
Location (Gene)
Renal Manifestations Other Manifestations
Birt-Hogg-Dubé
syndrome (BHD)
17p11.2
BHD
Hybrid oncocytic renal tumors,
chromophobe and clear cell renal
carcinomas, oncocytomas:
multiple, bilateral
Benign tumors of hair follicle
(fibrofolliculomas); lung
cysts, spontaneous
pneumothoraces
Constitutional
chromosome 3
translocation
3p; Not known;
VHL somatic
mutations 84% -
98%
Clear cell renal carcinoma:
multiple, bilateral
None
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24. Spread of renal cancer
Local Infiltration :through the renal capsule to involve the
perinephric fat and Gerota's fascia.
Venous: The tumor may grow directly along the venous channels
to the renal vein or vena cava.
Lymph node metastases :involve the renal hilar, para-aortic,
and paracaval lymph nodes
Distant metastasis: lung, bone, bone, liver ,adrenal
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25. Natural History
7% diagnosed incidentally
45% present with localized disease at time of diagnosis
25% with locally advanced disease at diagnosis
30% with metastatic disease at diagnosis
Lymph node metastases- 9% to 27% (renal hilar, para-aortic
and paracaval)
Renal vein – 21% & IVC 4%
Distant metastases- lung (75%), soft tissue (36%), bone
(20%), liver (18%), skin (8%) and CNS (8%)
Ref: DeVita

26. • CLINICAL FEATURES
50 % of RCC are now detected incidentally: Radiologist's tumor’
Triad of presentation: seen in only 10% pt., poor prognosis
Pain (80%),
Hematuria (45%)
palpable mass (15%)
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27. Other signs and symptoms
Weight loss (33%)
 Fever (20%)
 Hypertension (20%)
 Hypercalcemia (5%)
 Night sweats
 Malaise
 Varicocele usually left sided, due to obstruction of the
testicular vein (2% of males)
 Stauffer’s syndrome:
Non metastatic hepatic dysfunction reported in 3-20% of cases
Hepatic function normalizes in 60 to 70% of cases after nephrectomy.
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Paraneoplastic syndromes are found in 20% of
patients with RCC
Elevated E.S.R.
Hypertension
Anemia
Cachexia
Pyrexia
Abnormal liver function
Hyper calcemia
Polycythemia
Neuromyopathy

29. Clinical presentation
• History taking:
• age, Sex,Occupation
• Chief coimplains:
 Pain :onset, duration, progress, nature, radiation,
relation with micturition
 Renal pain: painless or dull ache, at renal angle
radiating along subcoastal area towards umbilicus
along with fever loss of weight malaise
 Ureteric pain: colic, start at renal angle radiate
downward along course of ureter,referred to groin
inner part of thigh, penis etc
 Bladder pain is midline suprapubic dull,
 Urethral pain: during or at end of micturition
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30. Haemeturia:
• Amount,
• Relation to micturition
• Association with pain
Beginning: urethral
Toward end: vesical
Throughout: prerenal,renal,vesical
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31. Renal lump
• History:site onset duration progression
• Examination
• Inspection,
• Palpation
• Percussion
• auscultation
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32. Inspection
in recumbent position
fulleness in lumbar region
moves slightly with respiration
palpation
murphy’s punch test
patient sits up
press over the renal angle to see for tenderness
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33. Palpation of kidney: bimanual method
• Features of a renal lump
• Lies in loin
• Can be moved in loin
• Reniform shape
• Ballotable
• slightly move with respiration
• fingers can be insinuated between coastal margin and swelling
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• To palpate the left kidney,
• reach across the client
• place your left hand under the client’s left flank with your palm upward.
• Elevate the left flank with your fingers, displacing the kidney upward.
• Ask the client to take a deep breath
• use the palmer surface of your right hand to palpate the kidney
• Repeat the technique for the right kidney

34. Percussion
features of a renal lump
resonant anteriorly due to bowel loops
dull posteriorly: enlarged kidney displaces colon
Auscultation: bruit may be heard
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35. Diagnostic Work-Up
• Laboratory studies
– CBC, LFT's, alkaline phosphatase, BUN, creatinine, urinalysis
• Radiographic studies- Increased use of imaging has increased the
detection of renal lesions most of which are simple cysts.
– X-Ray KUB region
– Ultrasonography- Excellent in distinguishing cystic from solid masses
– Intravenous Urography - Starting point for hematuria evaluations and
function of contralateral kidney
– Computed tomography- Provides an excellent assessment of the parenchyma
and nodal status.
– Magnetic Resonance Imaging - excellent demonstration of solid renal masses
and is image test of choice to demonstrate extent of vena caval involvement
with tumor. Useful in patients with renal insufficiency
– MRI has no advantage compared with contrast enhanced CT for the diagnosis
of RCC but it is better for staging of locally advanced cases
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36. Metastatic Work-Up
• Chest X-ray or Chest CT
• CT/MRI scan of abdomen or pelvis
• Bone scan with plan films (for elevated alkaline
phosphatase or bone pain).
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37. Radiological anatomy
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38. 38

39. Figure : Computed tomography
demonstrates a right renal carcinoma (m)
with a large contralateral adrenal
metastasis (a).
Figure: CT scan shows large left renal mass
with calcification (m) invading the left renal
vein (arrow).
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40. Figure: T1-weighted magnetic
resonance image demonstrates
tumor (m) and vascular invasion
(arrow). Flowing blood (v) in the
left renal vein is black on this
scan.
Figure A: Axial T1-weighted
image demonstrates a large left
renal carcinoma with extension
into the left renal vein (m) with
protrusion into the IVC (v). B:
Sagittal T1-weighted image
shows the relation of the tumor
thrombus (m) to the IVC (v) in
the lateral projection.
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41. Renal Cell Carcinoma
• 3D CT scan showing a left lower pole RCC extending into the
renal hilum

42. Renal Cell Carcinoma
• Multifocal renal cell carcinoma in a patient with Von Hippel Lindau disease.
Patient had already undergone a right nephrectomy. Contrast-enhanced CT
scan

43. Renal cell
carcinoma of
left kidney
involving renal
vein & inferior
vena cava
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45. Thank you !
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