Renal tumors can be benign or malignant. Benign renal tumors include cysts, oncocytomas, angiomyolipomas, and papillary adenomas. Malignant renal tumors mainly consist of renal cell carcinoma (RCC). RCC is the most common type of kidney cancer and its incidence is rising. Risk factors for RCC include smoking, obesity, hypertension, and family history. RCC is diagnosed using imaging tests like ultrasound, CT scan, MRI and biopsy when needed. RCC is classified based on histology and the TNM staging system is used to determine prognosis and treatment.

1. Renal Tumors
Dr.Faizan Rizvi

2. Classification of Renal Tumors
Benign
• Cyst
• Oncocytoma
• Angiomyolipoma
• Papillary Adenoma
• Juxtaglomerular Cells Tumor
• Leiomyoma
• Lipoma
• Hemangioma
Malignant
• RCC
• TCC
• Sarcoma
• Lymphoma
• Metastatic

3. Benign Tumors

4. Bosniak Classification For Renal Cysts

5. Renal Oncocytoma
• Benign renal tumor,3-5 % of renal masses
• Large epithelial cells contains fine granular eosinophilic cytoplasm
called oncocytes
• Surface is tan to light brown,central stellate scar,no necrosis
• CT/MRI cannot diagnose
• Diagnosed on histopathology,differentiated with chromophobe RCC
on the cytokeratin 7 which is rarely positive in oncocytoma

6. Angiomyolipoma( Renal Hemartoma)
• Three components: Blood vessels,smooth muscles and fat cells
• Diagnosed with CT or MRI
• Pathognomonic sign: -20 to -80 HU on CT
• Treatment:
• <4cm in size= Yearly follow up on USG/CT
• >4cm in size/mild symptoms= 6 month follow up on USG/CT
• Moderate to severe symptoms= Partial nephrectomy,Renal artery
embolization,immunosuppressive agents e.g sirolimus

7. Papillary Adenomas
• Incidental Finding in nephrectomy specimens
• Found more often with RCC
• Causes polycythemia

8. Juxtaglomerular cells tumor
• Arise from pericytes of afferent arterioles in juxtaglomerular
apparatus.
• Characterized by Hypertension, Hypokalemia , Hyperaldosteronism
and high renin content.
• Hypertension to refractory medical treatment.
• Diagnosed is confirmed by renal vein sampling for renin.
• Treatment: Partial/Complete Nephrectomy.

9. Leiomyomas
• Small rare tumors
• USG : hypoechoic
• CT non contrast: hyperdense
• CT contrast: hypodense
• Treated conservatively with observation

10. Hemangiomas
• Diagnosed on CT angio/MRI angio
• Managed by endoscopic fulguration or laser ablation

11. Malignant Tumors
..

12. RCC
• Cancer arising from the lining of proximal convoluted tubule.
• The most common type of kidney cancer.
• Also known as Renal Adenocarcinoma or Grawitz's Tumor.
• Most lethal of all the genitourinary tumors.

13. Epidemiology
• The incidence of renal cell carcinoma is rising steadily.
• More common in men than women,male to female ratio is 1.6:1.
• Blacks at an higher risk than whites.

14. Risk Factors
• Cigarette smoking.
• Obesity
• Hypertension
• Family history of the disease.
• Patients with inherited diseases like von Hippel Lindau disease
• Dialysis patients with acquired cystic disease of kidney show greater
risk.

15. Paraneoplastic Syndromes
Paraneoplastic syndromes include
• Hypercalcemia
• Hypertension
• Anemia,thrombocytosis
• Hepatopathy (Stauffer's syndrome).
• Renal cell carcinoma has a predilection for producing occlusive tumor
thrombi in the renal vein and the inferior vena cava (particularly from the
right), manifested by signs of lower extremity edema and acute scrotal
varicocele when occluding the left renal vein.This phenomenon of inferior
vena cava thrombus occurs in approximately 5% to 10% ofpatients.

16. Familial Syndromes associated with RCC
• Von Hipple Lindau Disease:
Clear Cell RCC,CNS Hemangiomas,Retinal Hemangiomas and
pheochromocytoma
• Hereditary leimyomatosis:
Papillary RCC,cutaneous leimyomas and uterine leiomyomas
• Birt Hogg-Dube Syndrome: Chromosome 17 mutation
Chromophobe clear cell RCC/oncytoma,lung cysts,pneumothorax
• Tuberous sclerosis: Hamarin gene mutation
Clear cell RCC,seizures,developmental delay and AML

17. Signs and Symptoms
• Classic triad of: Hematuria,Flank pain and Abdominal mass in 7-10% of patients
• 60-70% of renal Tumors are detected incidentally
• Other signs may include
• weight loss and anorexia
• Polycythemia
• Anemia
• Fracture of hip
• Varicocele.enlargement of testicle on left side
• Pallor
• Hirsutism
• Constipation
• Hypertension
• Hypercalcemia
• Leg and ankle swelling

18. Diagnosis
• History
• Physical examination:
• Fever
• High blood pressure
• Lab tests:
• Complete blood count
• Urinanalysis
• Serum calcium
• Imaging tests:
• Ultrasound abdomen
• Abdominal CT scan
• MRI scan
• PET scan
• Renal angiography
• Intravenous pyelogram
• Chest x rayBone scan
• Biopsy Fine needle aspiration
• Core needle biopsy

19. Classification of RCC
RCCs are classified into one of the following histological Subtype
• Conventional Clear Cell
• Papillary (Chromophilic)
• Chromophobe
• Collecting Duct
• Neuroendocrine

20. • Clear cells are rounded or polygonal with abundant cytoplasm, which
contains cholesterol, triglycerides, glycogen, and lipids.
• The cells present in the papillary (chromophilic) typecontain less
glycogen and lipids, and electron microscopy reveals that the granular
cytoplasm contains many mitochondria and cytosomes.
• Chromophobe-type carcinomas contain large polygonal cells with
distinct cell borders and reticulated cytoplasm, which can stain
diffusely withHale's colloidal iron.

21. 2017 TNM Classification System
• TX Primary tumour cannot be assessed
• TO No evidence of primary tumour
• T1 Tumors 7 cm or less in greatest dimension, limited to the kidney
• T1a Tumor 4 cm or less
• T1b Tumor > 4 cm but ≤7 cm
• T2 Tumor >7 cm in greatest dimension, limited to the kidney T2a Tumour > 7 cm but s 10 cmT2b Tumours> 10 cm, limited to the kidney
• T3Tumor extends into major veins or perinephric tissues but not into the ipsilateral adrenal gland and not beyond Gerota fascia T3a Tumour extends into the renal vein or its
segmental branches, or invades the pelvicalyceal system or Invades perirenal and/or renal sinus fat, but not beyond Gerota fascia
• T3b Tumor grossly extends into the vena cava below diaphragm
• T3c Tumor grossly extends into vena cava above the diaphragm or invades the wall of the vena
• T4 Tumor invades beyond Gerota fascia (including contiguous extension into the ipsilateral adrenal glandcava
• NX Regional lymph nodes cannot be assessed
• NO No regional lymph node metastasis
• N1 Metastasis in regional lymph node(s)
• MO No distant metastasis
• M1 Distant metastasis

22. Indications of Renal Biopsy
• Active surveillance of small renal masses <3cm
• Mass is concerning for metastatic,hematologic,infectious or
inflammatory etiology
• Patients who are not surgical candidates,ablative treatment is
planned