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Kidney

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Title: Pigmenty Author: Jaroslava DU KOV Last modified by: JAROSLAVA dU KOV Created Date: 10/10/2000 6:19:10 AM Document presentation format – PowerPoint PPT presentation

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Title: Kidney


1
Kidney Urinary Tract Neoplasms
  • Jaroslava DuÅ¡ková
  • Inst. Pathol. ,1st Med. Faculty,
  • Charles Univ. Prague
  • http//www1.lf1.cuni.cz/jdusk/

2
Kidney Cancer
  • 2 of the total human cancer burden, MF
    21, middle age
  • preference for developed
    (industrialized) countries
  • risk factors TOBACCO SMOKING,
    OBESITY

3
Symptoms
  • silent for a long time
  • - discovered by chance
  • hematuria, backache, abdominal mass,
    metastatic spread
  • early hematogenic spread possible

4
WHO classification of tumours of the kidney
(2004)
5
WHO Histogenetic groups (
number of nosology units identified)
  • Renal cell (12)
  • Metanephric (3)
  • Nephroblastic (3)
  • Mesenchymal (18)
  • Mixed mesenchymal and epithelial (3)
  • Neuroendocrine (5)
  • Hematopopietic and lymphoid (3)
  • Germ cell (2)
  • Metastatic (-)

6
Epithelial Neoplasms of the Pelvis
  • Benign - papillomas
  • Malignant - carcinomas
  • papillocarcinomas
  • squamous cell

Urinary ways
7
Kidney Tumours
  • Benign
  • Malignant

8
Kidney Adenoma
  • Definition
  • Formerly - diam. 2-3 cm
  • Recently only diam. less than 5mm without a
    clear cell component
  • tubulopapillary architecture
  • lack of atypiae mitoses

9
Epithelial Kidney Tumours
  • papillary tubulopapillary
  • (lt5mm!)
  • oncocytic (oncocytoma)
  • metanephric
  • benign
  • ADENOMAS

10
Oncocytoma
  • Kidney cortex
  • may be multicentric and bilateral
  • Macro tan with a central stellate scar
  • Micro - eosinophillic granular cytoplasm
    bizarre nuclei
  • Elmi mitochondria filling up the cytoplasm
  • Biological behaviour benign

11
Kidney Tumours - mesenchymal
  • Angiolipoleiomyoma mixed mesenchymal tumour

12
Metanephric Adenoma
  • small dark cells
  • acinar and glomeruloid formations
  • calkospherites, calcifying
  • non agressive

13
Benign Kidney Tumours Mimicking Carcinomas and
Sarcomas
  • Metanephric adenoma - large cellular
  • Oncocytoma - large with atypiae
  • Angioleiomyolipoma - large with atypiae

14
Epithelial Kidney Tumours
  • Clear Conventional Cell
  • Papillary (chromophillic)
  • type 1
  • type 2
  • Chromophobe
  • classical
  • eosinophillic
  • Sarcomatoid
  • Cystic
  • Collecting Duct
  • malignant
  • CARCINOMAS

15
Clear Cell Ca (Grawitz tumour) (75)
  • Solid / cystic
  • Unilocullar or multilocular
  • Micro - solid or tubulocystic
  • clear cytoplasm (fat glycogen)
  • Immunohistochemistry cytokeratins, vimentin,
    CD10, EMA, S-100
  • Cytogenetics deletion of the short arm
    chromosome 3 (3p)
  • Prognosis G, pT dependent
  • Sarcomatoid variant is the most malignant

16
Papillary (Chromophillic) Ca (10)
  • In dialysed more frequent
  • X-ray hypovascular
  • Histology papillary/ tubulopapillary
  • type 1 cubic cells
  • type 2 - cylindric cells (worse prognosis)
  • Genetics trisomy or tetrasomy 7 and 17
  • in men often Y chromosome missing
  • mutation of c-met oncogen
  • Prognosis G, pT dependent
  • slightly better than in conventional ca

17
Chromophobe Carcinoma (5)
  • Macro - brown color
  • Mikro - solid, cytoplasms clear or
    eosinophillic, positive in Hales
    colloidal iron staining,
  • raisin-like cell nuclei
  • Elmi microvesicles in cytoplasm
  • Genetics missing chromosomes -
  • 1, 2, 10, 13, 6, 21, 17
  • Prognosis G, pT dependent

18
Collecting Duct Carcinoma
  • Starts in the medulla
  • Micro
  • adenocarcinoma urothelial like
  • hobnail cells
  • papillary
  • fibroplasia, mucin production
  • Imuno cytokeratin 13, vimentin, lectin
  • Prognosis unfavourable

19
Nephroblastoma (Wilmstumour)
  • syn. - embryonal adenosarcoma
  • Children - preschool age
  • Macro gray-white large retroperitoneal mass
    palpable through abdominal wall
  • Micro undifferentiated renal blastema, tubular
    and glomeruloid formations may be present
  • Prognosis curable (stage!)
  • Follow up - nephroblastomatosis

20
Role of the Pathologist in the Kidney Tumour
Diagnostics
  • Typing
  • Biological Behaviour
  • Grading
  • Staging

21
Grading
  • Nuclear Fuhrman et al. 1982
  • Nuclear plus architecture
  • Proliferation factors - PCNA, Ki 67, Bcl 2
  • Morphometry
  • DNA Analysis
  • AgNOR
  • Angiogenesis
  • Cytometry Flow cytometry

22
Staging
  • Size
  • Kidney capsule infiltration
  • Angioinvasion
  • Metastases in the lymph nodes
  • Number of lymph nodes involved
  • Metastases in the surrounding organs

23
Nuclear Grading in Kidney Cancer (Fuhrman et al.
1982)
  • Grade I small, uniform, round (10 ? )
  • inaparent or missing nucleoli
  • Grade II larger irregular (15 ?)
  • nucleoli small
  • Grade III large, irregular margins (20 ?)
    nucleoli large
  • Grade IV large, bizarre, pleomorphic

24
Factors with an Adverse Prognosis Influence in
Kidney Cancer
  • Size diam. more than 12 cm
  • Invasion to venes recidives
  • Grading G III and G IV
  • Staging most important
  • Proliferation Index
  • p53 Expression

25
Kidney Cancer complications 1.
  • metastatic spread generalisation
  • manifestation via solitary bloodborne
    metastasis possible (pathological fracture,
    struma neoplastica)
  • hematuria anemia

26
Kidney Cancer complications 2.
  • hormon production erythropoietin
    polyglobulia
  • Wood L, Swanepoel C, du Toit A, Jacobs
    P.Clinically silent renal tumour producing
    erythropoietin. S Afr Med J. 2003
    Feb93(2)128-9.
  • Shaheen M, Hilgarth KA, Hawes D, Badve S, Antony
    AC.  A Mexican man with "too much blood".
  • Lancet. 2003 Sep 6362(9386)806.
  • insulin, glukagon, renin, HPL like substances

27
  • Urothelial Tumours

28
Urothelial Cancer
  • approx. 3 of total human cancer burden
  • increasing incidence
  • industrialized countries
  • risk factors TOBACCO SMOKING aniline dye
    industry
  • phenacetin
  • schistosomiasis

29
Symptoms
  • hematuria
  • (obstruction)
  • (metastases)

30
Terminology
  • the term
  • UROTHELIAL
  • be used rather than transitional...

31
Normal urothelium
  • multilayered
  • variable number of layers
  • empty bladder 4 - 6
  • full bladder 2 - 3

32
Variations of Urothelium slight reactive
changes
  • von Brunns nests
  • mucinous metaplasia
  • squamous metaplasia
  • (nonkeratinising, vagina type)

33
Metaplasia
  • Def change of one differentiated structure into
    another one
  • (e.g. urothelium squamous epithelium)

34
Metaplasia
  • Significance
  • dif. dg. problem
  • with atypia
  • precancerosis

35
The WHO/ISUP Consensus Classification of
Urothelial Neoplasmsof the Urinary Bladder
  • Epstein JI, Amin MB,Reuter VR, Mostofi FK,
  • the Bladder Consensus Conference Committee
  • Am.J. Surg.
    Pathol.,22,1998,1435-8

WHO 2004
36
The WHO/ISUP Consensus Classification
  1. Hyperplasia
  2. Flat lesions with atypia
  3. Papillary neoplasms
  4. Invasive neoplasms

37
The WHO/ISUP Consensus Classification
  • I. Hyperplasia
  • Flat
  • Papillary

38
Hyperplasia
  • Def regular increase in number of uroth. layers
    (min. gt7, mostly gt10)
  • slight increase in cell nuclei size,
  • preserved architecture

39
Hyperplasia
  • Significance precancerosis
  • 70 of patients with urothelial ca
    identical mutations

40
The WHO/ISUP Consensus Classification
  1. Hyperplasia
  2. Flat lesions with atypia
  3. Papillary neoplasms
  4. Invasive neoplasms

41
  • II. Flat lesions with atypia
  • Reactive (inflammatory) atypia
  • Atypia of unknown significance
  • Dysplasia (LG IUN)
  • CIS (HG IUN)

42
Dysplasia
  • DEF
  • disturbance of normal urothelium architecture
    cytology

43
Dysplasia
  • LG IUN low grade intraurothelial
    neoplasia
  • HG IUN/ CIS high grade intraurothelial
    neoplasia

44
The WHO/ISUP Consensus Classification
  1. Hyperplasia
  2. Flat lesions with atypia
  3. Papillary neoplasms
  4. Invasive neoplasms

45
  • III. Papillary neoplasms
  • Papilloma
  • Inverted papilloma
  • Papillary Urothelial Neoplasm of Low Malignant
    Potential PUNLMP
  • Papillary carcinoma, low grade
  • Papillary carcinoma, high grade

46
Papilloma WHO 1973 G0
  • Def circumscribed solitary papillary lesion
    covered with cytologically and architecturally
    normal urothelium.

47
Papillary neoplasm of low malignant
potential
  • Def.
  • well stratified urothelium bering features of
    slight dysplasia and increased number of layers

48
The WHO/ISUP Consensus Classification
  1. Hyperplasia
  2. Flat lesions with atypia
  3. Papillary neoplasms
  4. Invasive neoplasms

49
  • Invasive neoplasms
  • lamina propria invasion (pT1a,b)
  • muscularis propria (detrusor muscle)
    invasion (pT2a,b)
  • perivesical tissue macro/micro (pT3a,b)
  • surrounding organs/ abdominal wall
    (pT4a,b)

50
Less Common Types of Urinary Bladder Cancer
  • microcystic carcinoma
  • with  pseudosarcomatose stroma
  • with bone or chondroid stromal metaplasia
  • spinocellular
  • adenocarcinoma
  • undifferenciated ca
  • with trophoblastic differentiation
  • neuroendocrine

51
Non-Epithelial Bladder Tumours - Mesenchymal
  • leiomyomas and leiomyosarcomas rhabdomyosarcoma
    botryoides
  • rhabdoid
  • fibrohistiocytic
  • vascular (capilllary, cavernous and angiovenous
    hemangiomas and hemangiosarcomas)
  • malignant lymphomas

52
Non-Epithelial Bladder Tumours - Neuroectodermal
  • neurofibromas in Recklinghausens disease
  • melanoma
  • paraganglioma
  • composite pigmented paraganglioma-ganglioneuroma

53
Urinary Bladder Pseudotumors
  • inflammatory
  • malakoplakia
  • amyloid deposits
  • pseudosarcoma

54
Cystectomy Biopsy Report
  • MICRO
  • type, grade (G) and stage (pT) of the tumor
  • further urothelial abnormities
  • lymphatic and blood vessel invasion
  • presence / absence of the tumor in the
    resection margins and neighbouring organs
  • further abnormities of the neighbouring
    organs

55
Urinary Blader Cancer - complications
  • local recidives
  • progression
  • metastases
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