Renal tumors


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Renal tumors

  2. 2. Are non-cancerous growths of the kidney that do not metastasize to other sites in the body .They are not life-threatening but they can cause complaints if they exert pressure effects on adjacent structures.As there is universal increase in the use of radiological imaging, benign renal masses are being detected more frequently .
  4. 4. Most common benign renal parenchymal tumor.Discovered occasionaly at postmortem or incidentally during radiological imaging .Asymptomatic .Despite the classification of adenoma as a benign tumor, difficult to differentiate from renal carcinoma.Unknown etiology .Small and slow growing .Look very much like malignant RCCs.Previously, all renal tumors <3 cm were considered adenomas. However, even such small tumors can be of high grade .
  5. 5. adenoma kidney
  6. 6. Metanephric adenoma Normal renal parenchyma
  7. 7. Benign, unifocal renal tumor that averages 5 to 8 cm in diameter but can reach larger sizes; however, the presence of malignant elements has been known to occur.More often in men than women .Unknown etiology .Found incidentally .Partial or radical nephrectomy is the safest method of treatment because of unreliability of differentiating it from RCC preoperatively. .
  8. 8. Unusual tumors of the kidney .Often but not always associated with TUBEROUS SCLEROSIS .Histologically, they are composed of fat cells, blood vessels, and sheets of smooth muscle cells.Profuse internal hemorrhage can occur.
  9. 9. Malignant elements are present in about one- quarter of them and may lead to metastasis .Asymptomatic lesions smaller than 4 cm should be followed with yearly ultrasounds.Larger tumors should be considered for embolization or renal-sparing surgery.Conservative surgical therapy is necessary because of frequent bilaterality and multiplicity.
  10. 10. Normal kidney angomyolipoma angiomyolipomaNormalkidney The tumor has adipose tissue (the "lipoma" component) which blends with interlacing bundles of smooth muscle (the "myo" component) in which are scattered vascular spaces the "angio" component.
  11. 11. Rare .Small .Typically found in smooth muscle –containing areas of the kidney including renal capsule and renal pelvis .
  12. 12. Renal parenchyma liomyoma
  13. 13. liomyoma Renal tubules
  14. 14. Seen in middle aged females .Best detected radio-logically by CT scan .( due to high fat content .)
  15. 15. lipoma Mature adipocytes Normalkidney
  16. 16. Very small in size ( average 0.5 cm ) or lessAsymptomatic .More commonly found in women than men.Usually occur on the rim of the kidneyMay reach large size before being detected.Because they can’t be distinguished from malignant growths, they are often removed through partial or complete nephrectomy .
  17. 17. fibromaThis small round white nodule in the medulla is an incidental autopsy finding. They are generally 0.5 cm in size or less.
  18. 18. Normal renal parenchyma fibroma
  19. 19. PEADIATRIC RENAL TUMORS Wilm’s tumor ( nephroblastoma ) .RENAL TUMORS IN ADULTS Hypernephroma adenocarcinoma(RCC) Transitional cell tumor (TCC) of renal pelvis Squamous cell carcinoma
  20. 20. tumor
  21. 21. EPIDEMIOLOGY- The most common neoplasm of the kidney(75%) or up to 85% .- Arises from renal tubular cells .- ( 2 – 3 ) % of all adulthood cancers .- ( 40 % ) of patients die of cancer .- Most common in 6th & 7th decades .- Male : Female ratio 2:1
  22. 22. RISK FACTORS Male gender . Race ( African Americans > Caucasians ) Age ( 40 – 60 ) Smoking ( increase risk by 40% ) Obesity High caloric diet Lack of physical activity. Occupational exposure ( asbestose ,cadmium ) Family history of RCC . Specific treatments like dialysis – drugscertain pain relievers - like Phenacetin, diuretics
  23. 23. Medical diseases ( hypertension ) .Genetic and hereditary conditionsVon Hippel-Lindau (VHL) DiseaseHereditary Papillary Renal Cell CarcinomaBirt-Hogg-Dube SyndromeHereditary Leiomyomatosis Renal Cell Carcinoma SyndromeHereditary Renal OncocytomaPolycystic Kidney Disease
  24. 24. smoking High caloric diet Drugs Lack of physical activity
  25. 25. HISTOLOGIC TYPESClear cell RCC .Papillary RCC .Chromophobe RCC .Collecting duct RCC .Unclassified RCC .
  26. 26. RCCRenal cell carcinoma arising in the middle pole of the kidney. Fairly circumscribed, The cut surfacedemonstrates a yellowish areas, white areas, brown areas, and hemorrhagic red areas.
  27. 27. H&E CD 10
  28. 28. CK 7H&E
  30. 30. H&E
  31. 31. Occur anywhere in the urinary tract, but they aremost common in the bladder.Smoking, exposure to analine or azo dyes, andnapthylamine exposure are known to beassociated with urothelial cancers.Urothelial tumors often are multicentric .These patients need careful follow-up.
  32. 32. P63 staining in TCCH&E
  33. 33. - Rare . - Often associated with chronic inflammationresulting from stones. - Metastasize early and the prognosis is poor . -Radiosensitive
  34. 34. Adapted from
  35. 35. - More than 50% of these tumors are asymptomatic.Classic triad: pain, hematuria, and flank mass occur only rarely and indicate advanced disease.More frequent sign and symptoms are:PainHematuriaFlank massWeight lossHypertensionHypercalcemiaErythrocytosisVaricocele, usually left sided, due to obstruction of the testicular vein.
  36. 36. Paraneoplastic syndromes may occur as a result of renal tumor production of1,25 dihydroxycholecalciferol, rennin, erythropoietin, and other hormonesubstances RCC is known to produce biologically active productsthat result in clinically significant syndromes, including;Adrenocorticotropic hormone (Cushing’s syndrome),Prolactin (galactorrhea),Insulin (hypoglycemia),Gonadotropins (gynecomastia and decreased libido; orhirsutism, amenorrhea, and male pattern balding).A paraneoplastic syndrome confer a poor prognosis.Patients whose paraneoplastic metabolic disturbances failto normalize after nephrectomy suggests presence ofclinically undetectable metastatic disease and have verypoor prognosis.
  37. 37. Stauffer’s syndrome is a reversible syndrome ofhepatic dysfunction in the absence of hepaticmetastases associated with RCC and can occur inup to 20% of patients.Hepatic function abnormalities include elevationof alkaline phosphatase and bilirubin,hypoalbuminemia, prolonged prothrombin time,and hypergammaglobulinemia.Stauffer’s syndrome tends to occur in associationwith fever, fatigue, and weight loss and typicallyresolves after nephrectomy. It may be due tooverproduction of granulocyte-macrophagecolony stimulating factor by the tumor.
  38. 38. Hypertension, supraclavicular adenopathy, and flank or abdominal mass with bruit.Approximately 30% of patients with renal carcinoma present with metastatic disease.Metastatic disease involve organs ; Lung (75%) Soft tissues (36%) Bone (20%) Liver (18%) Cutaneous sites (8%) Central nervous system (8%) Varicocele and findings of paraneoplastic syndromes raise clinical suspicion for this diagnosis..
  39. 39. Laboratory studies in the evaluation of renal cell carcinoma should include a workup for paraneoplastic syndromes. Initial studies - Complete Urine analysis -CBC -Electrolytes -Renal profileLiver function testsCalciumERSPTAPTTOther tests indicated by presenting symptoms
  40. 40. IMAGING ; IVU ; to fully evaluate upper & lower UTCT - A CT scan without and with intravenous (IV) contrast (renal protocol) is the method of choice to evaluate a renal mass .- Any mass that enhances with IV contrast should be considered an RCC until proven otherwise.- CT provides information on renal vein and inferior vena cava involvement, lymph node metastases, and perirenal involvment of the adjacent organs.MRI, help differentiate solid and cystic renal masses and is particularly useful in patients who cannot receive IV contrast agents.MRI has become the best study to evaluate the IVC for tumor thrombus.
  41. 41. Metastatic WorkupMetastatic workup should include routine chest radiograph, IVU, CT, liver function tests, and serum calcium. A bone scan should be obtained in any patient with skeletal pain or other evidence of metastatic disease ..
  42. 42. 1 . Surgery : Simple enculation Partial nephrectomy . Radical nephrectomy .Radical nephrectomy ; removal of kidney , perinephric fat,fascia gerota,suprarenal gland, upper half of the ureter.(lymph nodes not part pf radical nephrectomy). Minimal invasive . open/laparoscope2. Chemo/radiotherapy .3. Immune therapy.
  43. 43. Radical nephrectomy includes the removalof the tumour-bearing kidney.It remains the gold standard curative therapyfor patients with localised renal cellcarcinoma (RCC)Nephron-sparing surgery considered forpatients with a localised tumour less than 4cm in diameter. It involves partial nephrectomy withpreservation of as much functioning kidneytissue as possible.
  44. 44. Palliative nephrectomyIn patients with Metastatic disease for alleviation of symptomssuch as pain, hemorrhage, malaise, hypocalcaemia, erythrocytosis,or hypertension.Several randomized studies are now showing improved overallsurvival in patients presenting with Metastatic kidney cancer whohave nephrectomy followed by either interferon or IL-2.
  45. 45. Patient who are not suitable candidates for surgeryAblation :Kidney tumors be removed (ablated) with intense heat or cold, in whichspecial needles are inserted through the skin, guided by imaging from a CTscan and ultrasound.Percutaneous cryoablation — Cryoprobes freeze the tumor with intense cold.The treatment lasts about 30 minutes.Percutaneous radiofrequency ablation — Electrodes deliverradiofrequency energy to the tumor, and the intense heat destroys thetumor in five to 15 minutes.Angioemoblization
  46. 46. Laparoscopic surgeryThe recovery from a laparoscopicnephrectomy is remarkable. Suffer a lot less from the smallerscars than the conventional surgicalscar.Any laparoscopic procedure is ahighly technical undertaking andno-one can guarantee thatconversion to the older style openoperation will not be necessary.
  47. 47. Unfortunately, RCC is very resistant to chemotherapyand there is no standard effective treatment of RCC withpresent-day chemotherapy drugs. Some drugs, such asvinblastine, floxuridine, and 5-fluorouracil are mildlyeffective.Immune therapy; (interferon alpha , IL2)Anti-angiogenesis therapies; to reduce the blood supplyto the tumor, slowing or stopping growth of the tumorTargeted therapies; to growth of the cancer
  48. 48. T1 about 95%T2 about 88-90%T3 about 60%T4 about 0-25%
  49. 49. For stage I and II disease:Complete history, physical examination, chest radiographs, LFTs,BUN , serum creatinine, and calcium are recommended every 6months for 2 years and then annually for 5 years.Abdominal CT scan is recommended once at 4-6 months .For stage III renal cell carcinoma, Physical examination, chest radiographs, LFTs, BUN, serumcreatinine, and calcium are recommended every 4 months for 2 years,then every 6 months for 3 years, and then annually for 5 years.Abdominal CT scan should be performed at 4-6 months, thenannually or as indicated.Careful surveillance of patients with end-stage renal disease byultrasonography and CT scan is recommended.
  51. 51. EpidemiologySecond most common pediatric abdominal tumor and most common renal malignancyIncidence of Wilms tumor is 8 cases per millionchildren under age 15About 500 new cases per yearAccounts for 6% of all childhood malignant tumorsPresents between age 1-5; most commonly age 366% before age 595% before age 10
  52. 52. No tumor-specific symptoms1/3rd patients may have anorexia, vomiting, malaiseMost common presentation is painless abdominalmassPhysical ExamSmooth, palpable large abdominal massMay reveal HTNHematuriaAssociated congenital abnormalitiesCheck labs – associated with Von Willebrand’sDisease in up to 10% of cases
  53. 53. Is thought to rise fromfoci of persistentmetanephric cells callednephrogenic restsThese normally occur in1% of newborn kidneysand regress in earlychildhoodMultiple foci ofnephrogenic rests iscallednephroblastomatosis
  54. 54. Wilms’ tumor consists ofthree cell types(a) Tubular(b) Blastemal(c) StromalAll three are present inWilms’ tumor andconsidered FavorableHistology
  55. 55. Despite malignancy, excellent results if it can betreated aggressively with combination ofradiotherapy, surgery and chemotherapyPts who receive pre-op chemo and those whohave primary resection have an equal rate ofcomplications, but more complications are seen inthe primary resection group.
  56. 56. Adapted from
  57. 57. Adapted from
  58. 58. Adapted from webpathology .com
  59. 59. Adapted from
  60. 60. A 3-year-old child has become more irritable over the pasttwo months and does not want to eat much at meals. Onphysical examination the pediatrician notes an enlargedabdomen and can palpate a mass on the right. An abdominalCT scan reveals a 10 cm solid mass involving the rightkidney. The resected mass has a microscopic appearancewith sheets of small blue cells along with primitive tubularstructures. The child receives chemotherapy and radiationtherapy, and there is no recurrence.Which of the following neoplasms is this child most likely tohave had?A AngiomyolipomaB Renal cell carcinomaC Urothelial carcinomaD Wilms tumor
  61. 61.  A 50-year-old man has noted passing darker urine for the past week. On physical examination there are no abnormal findings. A urinalysis shows pH 5.5, specific gravity 1.013, 2+ blood, no protein, and no glucose. A urine cytology is performed and there are atypical uroepithelial cells seen. A urologist performs a cystoscopy, but no mucosal lesions are noted. He has a 60 pack year history of smoking cigarettes.Which of the following is the most likely diagnosis?A Adenocarcinoma of prostateB Urothelial carcinoma of renal pelvisC Acute interstitial nephritisD Nodular glomerulosclerosisE Squamous cell carcinoma of penis
  62. 62. http//www.sciencedirect.con/science/articleshttp//