Title: Kidney
1Kidney Urinary Tract Neoplasms
- Jaroslava Dušková
- Inst. Pathol. ,1st Med. Faculty,
- Charles Univ. Prague
- http//www1.lf1.cuni.cz/jdusk/
2Kidney Cancer
- 2 of the total human cancer burden, MF
21, middle age - preference for developed
(industrialized) countries - risk factors TOBACCO SMOKING,
OBESITY
3Symptoms
- silent for a long time
- - discovered by chance
- hematuria, backache, abdominal mass,
metastatic spread - early hematogenic spread possible
-
4WHO classification of tumours of the kidney
(2004)
5WHO 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 (-)
6Epithelial Neoplasms of the Pelvis
- Benign - papillomas
- Malignant - carcinomas
- papillocarcinomas
- squamous cell
Urinary ways
7Kidney Tumours
8Kidney Adenoma
- Definition
- Formerly - diam. 2-3 cm
- Recently only diam. less than 5mm without a
clear cell component - tubulopapillary architecture
- lack of atypiae mitoses
9Epithelial Kidney Tumours
-
- papillary tubulopapillary
- (lt5mm!)
- oncocytic (oncocytoma)
- metanephric
10Oncocytoma
- 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
11Kidney Tumours - mesenchymal
- Angiolipoleiomyoma mixed mesenchymal tumour
12Metanephric Adenoma
- small dark cells
- acinar and glomeruloid formations
- calkospherites, calcifying
- non agressive
13Benign Kidney Tumours Mimicking Carcinomas and
Sarcomas
- Metanephric adenoma - large cellular
- Oncocytoma - large with atypiae
- Angioleiomyolipoma - large with atypiae
14Epithelial Kidney Tumours
- Clear Conventional Cell
- Papillary (chromophillic)
- type 1
- type 2
- Chromophobe
- classical
- eosinophillic
- Sarcomatoid
- Cystic
- Collecting Duct
15Clear 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
16Papillary (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
17Chromophobe 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
18Collecting Duct Carcinoma
- Starts in the medulla
- Micro
- adenocarcinoma urothelial like
- hobnail cells
- papillary
- fibroplasia, mucin production
-
- Imuno cytokeratin 13, vimentin, lectin
- Prognosis unfavourable
19Nephroblastoma (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
20Role of the Pathologist in the Kidney Tumour
Diagnostics
- Typing
- Biological Behaviour
- Grading
- Staging
21Grading
- Nuclear Fuhrman et al. 1982
- Nuclear plus architecture
- Proliferation factors - PCNA, Ki 67, Bcl 2
- Morphometry
- DNA Analysis
- AgNOR
- Angiogenesis
- Cytometry Flow cytometry
22Staging
- Size
- Kidney capsule infiltration
- Angioinvasion
- Metastases in the lymph nodes
- Number of lymph nodes involved
- Metastases in the surrounding organs
23Nuclear 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
24Factors 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
25Kidney Cancer complications 1.
- metastatic spread generalisation
- manifestation via solitary bloodborne
metastasis possible (pathological fracture,
struma neoplastica) - hematuria anemia
26Kidney 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 28Urothelial Cancer
- approx. 3 of total human cancer burden
- increasing incidence
- industrialized countries
- risk factors TOBACCO SMOKING aniline dye
industry - phenacetin
- schistosomiasis
29Symptoms
- hematuria
- (obstruction)
- (metastases)
30Terminology
- the term
- UROTHELIAL
- be used rather than transitional...
31Normal urothelium
- multilayered
- variable number of layers
- empty bladder 4 - 6
- full bladder 2 - 3
-
32Variations of Urothelium slight reactive
changes
- von Brunns nests
- mucinous metaplasia
- squamous metaplasia
- (nonkeratinising, vagina type)
33Metaplasia
- Def change of one differentiated structure into
another one - (e.g. urothelium squamous epithelium)
34Metaplasia
- Significance
- dif. dg. problem
- with atypia
- precancerosis
35The 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
36The WHO/ISUP Consensus Classification
- Hyperplasia
- Flat lesions with atypia
- Papillary neoplasms
- Invasive neoplasms
37The WHO/ISUP Consensus Classification
- I. Hyperplasia
- Flat
- Papillary
38Hyperplasia
- Def regular increase in number of uroth. layers
(min. gt7, mostly gt10) - slight increase in cell nuclei size,
- preserved architecture
39Hyperplasia
- Significance precancerosis
- 70 of patients with urothelial ca
identical mutations
40The WHO/ISUP Consensus Classification
- Hyperplasia
- Flat lesions with atypia
- Papillary neoplasms
- Invasive neoplasms
41- II. Flat lesions with atypia
- Reactive (inflammatory) atypia
- Atypia of unknown significance
- Dysplasia (LG IUN)
- CIS (HG IUN)
42Dysplasia
- DEF
- disturbance of normal urothelium architecture
cytology
43Dysplasia
- LG IUN low grade intraurothelial
neoplasia - HG IUN/ CIS high grade intraurothelial
neoplasia
44The WHO/ISUP Consensus Classification
- Hyperplasia
- Flat lesions with atypia
- Papillary neoplasms
- 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
46Papilloma WHO 1973 G0
- Def circumscribed solitary papillary lesion
covered with cytologically and architecturally
normal urothelium.
47Papillary neoplasm of low malignant
potential
- Def.
- well stratified urothelium bering features of
slight dysplasia and increased number of layers
48The WHO/ISUP Consensus Classification
- Hyperplasia
- Flat lesions with atypia
- Papillary neoplasms
- 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)
50Less 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
51Non-Epithelial Bladder Tumours - Mesenchymal
- leiomyomas and leiomyosarcomas rhabdomyosarcoma
botryoides - rhabdoid
- fibrohistiocytic
- vascular (capilllary, cavernous and angiovenous
hemangiomas and hemangiosarcomas) - malignant lymphomas
52Non-Epithelial Bladder Tumours - Neuroectodermal
- neurofibromas in Recklinghausens disease
- melanoma
- paraganglioma
- composite pigmented paraganglioma-ganglioneuroma
53Urinary 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
55Urinary Blader Cancer - complications
- local recidives
- progression
- metastases