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ANGGA NUGRAHA - 0918011103

Pielonefritis kronis
Tujuan Praktikum Mahasiswa mampu memahami dan menganalisa kasus pielonefritis khronis ditinjau dari ilmu patologi anatomi Petunjuk Praktikum 1. Mahasiswa diberikan ilustrasi kasus disertai beberapa gambar 2. Mahasiswa mempersiapkan mikroskop dan preparat sesuai skenario 3. Mahasiswa mengamati, mengevaluasi, dan menganalisa preparat sesuai skenario. 4. Mahasiswa mengambar hasil mikroskopis yang telah diamati 5. Mengerjakan tugas-tugas pertanyaan yang telah disediakan Dasar Teori Chronic pyelonephritis is renal injury induced by recurrent or persistent renal infection. It occurs almost exclusively in patients with major anatomic anomalies, including urinary tract obstruction, struvite calculi, renal dysplasia, or, most commonly, vesicoureteral reflux (VUR) in young children. Sometimes, this diagnosis is established based on radiologic evidence obtained during an evaluation for recurrent urinary tract infection (UTI) in young children. VUR is a congenital defect that results in incompetence of the ureterovesical valve due to a short intramural segment. The condition is present in 30-40% of young children with symptomatic UTIs and in almost all children with renal scars. VUR may also be acquired by patients with a flaccid bladder due to spinal cord injury. VUR is classified into 5 grades (I-V), according to the increasing degree of reflux. Pathophysiology Chronic pyelonephritis is associated with progressive renal scarring, which can lead to end-stage renal disease (ESRD), for example, reflux nephropathy. Intrarenal reflux of infected urine is suggested to induce renal injury, which heals with scar formation. In some cases, scars may form in utero in patients with renal dysplasia with perfusion defects. Infection without reflux is less likely to produce injury. Dysplasia may also be acquired from obstruction. Scars of high-pressure reflux can occur in persons of any age. In some cases, normal growth may lead to spontaneous cessation of reflux by age 6 years. Factors that may affect the pathogenesis of chronic pyelonephritis are as follows: (1) the sex of the patient and his or her sexual activity; (2) pregnancy, which may lead to progression of renal injury with loss of renal function; (3) genetic factors; (4) bacterial virulence factors; and (5) neurogenic bladder dysfunction. In cases with obstruction, the kidney may become filled with abscess cavities (see Pyonephrosis). Frequency VUR may be present in 30-45% of children with UTIs. The prevalence rate of VUR in siblings of patients with chronic pyelonephritis is approximately 35%. VUR and chronic pyelonephritis are less common in African American children than in white children. Mortality/Morbidity Conditions associated with mortality and morbidity related to chronic pyelonephritis include the following: (1) progressive renal scarring, (2) proteinuria, (3) hypertension, (4) end-stage renal disease, (5) focal glomerulosclerosis, and (6) xanthogranulomatous pyelonephritis (XPN). XPN occurs in 8.2% of patients and in 25% of patients with pyonephrosis. Race Chronic pyelonephritis is 3 times more common in white children than in African American children. Sex Chronic pyelonephritis is 2 times more common in females than in males. Age Chronic pyelonephritis occurs more often in infants and young children (younger than 2 y) than in older children and adults. Clinical History

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Physical

Many cases of VUR are suggested based on prenatal sonography findings. Patients with chronic pyelonephritis may report the following: o Fever o Lethargy o Nausea and vomiting o Flank pain or dysuria Some children may present with failure to thrive. The following may be noted: o Hypertension o Failure to thrive in young children o Flank tenderness Chronic pyelonephritis is renal injury induced by recurrent or persistent renal infection.

Causes

Skenario

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ANGGA NUGRAHA . disertai ureter panjang 21 cm. Diputuskan nefrektomi. berat 100 gram. Hasil pemeriksaan urin ditemukan banyak sel radang dan eritosit. Hasil scanning tampak ginjal kanan membesar diserati identasi pada ginjal. Hasil rontgen IVP Gambar 2.0918011103 Seorang wanita berumur 48 tahun mengeluh nyeri pinggang kanan dan buang air kecil warna merah sejak 2 minggu yang lalu. terdapat dilatasi pada kalik serta ditemukan batu. hasil operasi diperiksa histopatologi. Hasil Scanning penderita pyelonefritis Makroskopis Jaringan ginjal berukuran 11x6x4 cm. dilakukan pemeriksaan IVP tampak ginjal kanan membesar. 2 . . Gambar 1. Pada sayatan berwarna putih kecoklotan dengan konsistensi kenyal padat.

Mikroskopis penderita pyelonefritis Kesimpulan Pielonefritis kronis Tugas 1.0918011103 Gambar3. Tubulus proksimal dan tubulus distal sebagian besar mengalami degenerasi amiloid dan tampak deposit amiloid pada jaringan ikat diantara tubulus. Gambar 4. 2. Makroskopis pyelonefritis Mikroskopis Jaringan ginjal menunjukan gambaran pada korteks tampak glamerulus dengan capsule bowman yang mengalami sclerosis. Disekitarnya Tampak serbukan mosif sei radang limfosit. Pada pielum tampak ductus colligentes yang berdilatasi dan dalam lumen dengan eritrosit. 3. beri keterangan gambar yang telah dibuat! Jelaskan penyebob pyelonefritis khronis! Apakah terdapat kemungkinan terjadi keganasan? Jelaskan! 3 .ANGGA NUGRAHA . Gambar atau buat foto mikroskopis.

fibrous tissue. a triphasic nephroblastoma comprises three elements:  blastema  mesenchyme  epithelium Wilms' tumor is a malignant tumor containing metanephric blastema. Mahasiswa mengamati. bone. Mahasiswa mengambar hasil mikroskopis yang telah diamati 5. Its common name is an eponym. fat tissue.Contains well developed components mentioned above  Anaplastic . The mesenchymal component may include cells showing rhabdomyoid differentiation.Contains diffuse anaplasia (poorly developed cells) Prognosis Tumor-specific loss-of-heterozygosity (LOH) for chromosomes 1p and 16q identifies a subset of Wilms' tumor patients who have a significantly increased risk of relapse and death. dan menganalisa preparat sesuai skenario. Pathology Most nephroblastomas are unilateral. mengevaluasi. being bilateral in less than 5% of cases.ANGGA NUGRAHA . They tend to be encapsulated and vascularized tumors that do not cross the midline of the abdomen. In such cases. In cases of metastasis it is usually to the lung. The tumor is compressing the normal kidney parenchyma. Pathologically. Characteristic is the presence of abortive tubules and glomeruli surrounded by a spindled cell stroma. Early removal tends to promote positive outcomes. referring to Dr. a minority (25%) is associated with other developmental abnormalities. Approximately 500 cases are diagnosed in the U. A rupture of Wilms' tumor puts the patient at risk of hemorrhage and peritoneal dissemination of the tumor. The overall prognosis with surgical removal is positive. The majority (75%) occur in otherwise normal children. Genome-wide copy number and LOH status can be assessed with virtual karyotyping of tumor cells (fresh or paraffin-embedded). Molecular biology 4 . Wilms' tumors may be separated into 2 prognostic groups based on pathologic characteristics:  Favorable . surgical intervention by a surgeon who is experienced in the removal of such a fragile tumor is imperative.0918011103 Tumor Wilms Tujuan Praktikum Mahasiswa mampu memahami dan menganalisa kasus Tumor Wilms ditinjau dari ilmu patologi anatomi Petunjuk Praktikum 1. the German surgeon (1867–1918) who first described this kind of tumor. LOH for these chromosomal regions can now be used as an independent prognostic factor together with disease stage to target intensity of treatment to risk of treatment failure. The rhabdomyoid component may itself show features of malignancy (rhabdomyosarcomatous Wilms). with about 90% of patients surviving at least five years. stromal and epithelial derivatives. It is highly responsive to treatment. Max Wilms. annually. Mahasiswa mempersiapkan mikroskop dan preparat sesuai skenario 3. 4. Mengerjakan tugas-tugas pertanyaan yang telah disediakan Dasar Teori Wilms' tumor Wilms' tumor or Wilms' tumour (see spelling differences) or nephroblastoma is cancer of the kidneys that typically occurs in children. The stroma may include striated muscle.S. cartilage. rarely in adults. Mahasiswa diberikan ilustrasi kasus disertai beberapa gambar 2.

These tumors are more resistant to the chemotherapy traditionally used in children with Wilms’ tumor (favorable histology). liver. or lymph node metastases outside the abdomenopelvic region. an attempt should be made to stage each side according to the above criteria (stage I to III) on the basis of extent of disease prior to biopsy. Risk Factors People of African descent have the highest rates of Wilms' tumor. This is due to them being treated less aggressively and consistently. If the tumor is only in the kidney (typical).  Any of the following conditions may also exist: o Tumor involvement of the blood vessels of the renal sinus and/or outside the renal parenchyma. confined to the flank. Adjuvant chemotherapy is sometimes used. o The tumor has been biopsied prior to removal or there is local spillage of tumor during surgery.  Positive surgical margins.  The tumor is not ruptured or biopsied (open or needle) prior to removal. 1 or more of the following criteria must be met:  Unresectable primary tumor. or transected tumor thrombus. who looks at it under a microscope to check for signs of cancer. bone.ANGGA NUGRAHA . EG: less than 2 years old and less than 550g only requires Nephrectomy with observation Outcome: 98% 4-year survival. Most cases do not have mutations in any of these genes. The 4-year survival was 94% for those patients whose most advanced lesion was stage I or stage II.gov).  Lymph node metastasis. WTX. Treatment: Nephrectomy + abdominal radiation + 24 weeks of chemotherapy Outcome: 96% 4-year survival. a piece of the tumor will be removed. the gene encoding the proto-oncogene beta-catenin. Note: For patients with bilateral involvement. Skenario 5 . 70% 4-year survival if anaplastic Stage III (23% of patients) For Stage III Wilms' tumor. represent a higher-risk group. it can be removed along with the whole kidney (a nephrectomy). Treatment: Individualized therapy based on tumor burden Stage I-IV Anaplasia Children with stage I anaplastic tumors have an excellent prognosis (80-90% five-year survival). Staging and treatment Staging is determined by combination of imaging studies and pathology findings if the tumor is operable (adapted from www. Treatment: Abdominal radiation + 24 weeks of chemotherapy + nephrectomy after tumor shrinkage Outcome: 95% 4-year survival. 1 or more of the following criteria must be met:  Tumor extends beyond the kidney but is completely excised. Females are also more likely than males to develop the tumors.18 weeks of chemotherapy depending on age of patient and weight of tumor. 85% 4-year survival if anaplastic Stage II (23% of patients) For Stage II Wilms' tumor. They can be managed with the same regimen given to stage I favorable histology patients. Children 16 years old or older have higher mortality rates within their stages. Treatment strategy is determined by the stage: Stage I (43% of patients) For stage I Wilms' tumor. however. If there are tumors in both kidneys or if the tumor has spread outside the kidney. and require more aggressive regimens.  No residual tumor apparent at or beyond the margins of excision. 1 or more of the following criteria must be met:  Tumor is limited to the kidney and is completely excised. Children with stage II through stage IV diffuse anaplasia. 17% 4-year survival if anaplastic Stage V (5% of patients) Stage V Wilms’ tumor is defined as bilateral renal involvement at the time of initial diagnosis. 56% 4-year survival if anaplastic Stage IV (10% of patients) Stage IV Wilms' tumor is defined as the presence of hematogenous metastases (lung.  No residual tumor apparent beyond the margins of excision. Treatment Once a kidney tumor is found. according to research published in 2007. a surgical biopsy is done. At least half of the Wilms' tumors with mutations in WT1 also carry mutations in CTNNB1.0918011103 Mutations of the WT1 gene on chromosome 11 p 13 are observed in approximately 20% of Wilms' tumors. Treatment: Nephrectomy + abdominal radiation + 24 weeks of chemotherapy + radiation of metastatic site as appropriate Outcome: 90% 4-year survival. 76% for those whose most advanced lesion was stage III.  No involvement of renal sinus vessels. A sample of tissue from the tumor is sent to a pathologist. is inactivated in up to 30% of Wilms' tumor cases.cancer.  The surface of the renal capsule is intact.  Tumor spillage involving peritoneal surfaces either before or during surgery. Most instances of cancer occur among children under the age of 5. or brain). Treatment: Nephrectomy +/. A gene on the X chromosome.

warna putih bentuk benjol. homhogen padat dengan bercak-bercak perdarahan. Mikroskopis penderita tumor Wilms Kesimpulan Tumor Wilm's Tugas 1. diputuskan operasi dan massa tumor ginjal kiri di angkat untuk pemeriksaan patologi. Ketiga: komponen epitel terdiri dari sel kuboid yang menyusun dengan lumen dikelilingi sel tumor seperti sel basal. Pada irisan penampang kopsel tidak jelas. permukaan putih konsistensi kenyal. sitoplasma tipis. Kedua : komponen mesenkim terdiri dari sel spindle seperti fibroblast.0918011103 Seorang anak laki-laki berusia 3 tahun. Gambar 7. Scanning abdomen penderita tumor Wilms Makroskopis Massa tumor ukuron 10 x 8 x 8 cm. inti bulat hiper kromatis. putih abu. Pada pemeriksaan teraba massa tumor pada rongga perut kiri sebesar tinju orang dewasa. Rontgen foto abdomen tampak bayangan radiopoque menempati daerah ginjal kiri yang menekan kolon. Pertama : komponen blostomatous terdiri dari sel bulat kecil. Mikroskopis tumor Wilms Gambar atau buat foto mikroskopis. Gambar 5. sejak 1 tahun yang lalu perut makin membucit.ANGGA NUGRAHA . Gross hasil operasi ginjal penderita tumor Wilms Mikroskopis Sediaan massa tumor terdiri dari 3 bentuk sel. 2. Pada setiap daerah perbandingan selularitas 3 komponen berfariasi. 3. padat. beri keterangan gambar yang telah dibuat! Gambaran khas tumor Wilm's? Jelaskan penyebab tumor Wilm's? 6 . tidak tampak struktur ginjal normal. inti lonjong. buang air kecil ada kalanya kemerahan. Gambar 8. Gambar 6.

Mahasiswa mempersiapkan mikroskop dan preparat sesuai skenario 3.  Vision abnormalities  Pallor or plethora  Hirsutism .  The presenting symptom may be due to metastatic disease.Excessive hair growth (females) 7 . the majority of renal tumors are asymptomatic and are detected incidentally on imaging. RCC is the most common type of kidney cancer in adults. usually on the left (2% of cases).  Signs and symptoms A wide range of symptoms can be present with renal carcinoma depending on which areas of the body have been affected. bevacizumab. This triad only occurs in 10-15% of cases. interferon-alpha. flank pain and an abdominal mass. temsirolimus. Targeted cancer therapies such as sunitinib. there may be erythrocytosis (increased production of red blood cells) due to increased erythropoietin secretion. It is resistant to radiation therapy and chemotherapy. The classic triad is hematuria (blood in the urine). 4. responsible for approximately 80% of cases. Mahasiswa mengamati. but this is lowered considerably where metastases have spread.ANGGA NUGRAHA . the very small tubes in the kidney that filter the blood and remove waste products. weight loss or anorexia (30% of cases)  Polycythemia (5% of cases)  Anaemia resulting from depression of erythropoietin (30% of cases) Also. usually for an unrelated cause. and possibly sorafenib have improved the outlook for RCC (progression-free survival). this typically does not occur on the right as the right gonadal vein drains directly into the inferior vena cava. mengevaluasi. Mahasiswa mengambar hasil mikroskopis yang telah diamati 5. Mengerjakan tugas-tugas pertanyaan yang telah disediakan Dasar Teori Renal cell carcinoma Renal cell carcinoma (RCC. although they have not yet demonstrated improved survival. Today. This is due to blockage of the left testicular vein by tumor invasion of the left renal vein. It is also known to be the most lethal of all the genitourinary tumors. Signs may include:  Abnormal urine color (dark. rusty.0918011103 Karsinoma sel renal Tujuan Praktikum Mahasiswa mampu memahami dan menganalisa kasus karsinoma sel renal ditinjau dari ilmu patologi anatomi Petunjuk Praktikum 1.[2] Where the tumour is confined to the renal parenchyma. the enlargement of one testicle. dan menganalisa preparat sesuai skenario. also known as hypernephroma) is a kidney cancer that originates in the lining of the proximal convoluted tubule. the 5-year survival rate is 60-70%. such as a pathologic fracture of the hip due to a metastasis to the bone  Varicocele. or brown) due to blood in the urine (found in 60% of cases)  Loin pain (found in 40% of cases)  Abdominal mass (25% of cases)  Malaise. and is generally indicative of more advanced disease. although some cases respond to immunotherapy. Initial treatment is most commonly a radical or partial nephrectomy and remains the mainstay of curative treatment. Mahasiswa diberikan ilustrasi kasus disertai beberapa gambar 2.

PRCC)  Chromophobe renal cell carcinoma  Collecting duct carcinoma Renal epithelial neoplasms have characteristic cytogenetic aberrations that can aid in classification. 10% of RCC will contain calcifications. Dialysis patients with acquired cystic disease of the kidney showed a 30 times greater risk than in the general population for developing RCC.       8 . Radiology The characteristic appearance of renal cell carcinoma (RCC) is a solid renal lesion which disturbs the renal contour. HNF1B. which is predominantly transitional cell type. Upon physical examination. TFE3. Hysterectomy is associated with an approximately doubled risk. However. [13] See also Atlas of Genetics and Cytogenetics in Oncology and Haematology. hereditary papillary renal cancer. [17] Note: in epidemiology. Recent genetic studies have altered the approaches used in classifying renal cell carcinoma. 10. male 2372. patients with sickle cell trait are predisposed to developing Renal medullary carcinoma. Hormonal factors or injury of the ureter during surgery were considered as possible causes. RCC is registered together with renal pelvis carcinoma. H&E stain. Risk factors Cigarette smoking and obesity are the strongest known risk factors. show an enhanced risk of RCC. Traditionally 85 to 90%% of solid renal masses will turn out to be RCC but this number may be decreasing as renal masses are being found at smaller and smaller sizes with larger numbers of benign lesions. Nearly 51190 new diagnoses and 12890 deaths reported in the United States in 2007. See also Virtual Karyotype for CLIA certified laboratories offering array-based karyotyping of solid tumors. 2. It is more common in men than women: the male-to-female ratio is 1. 17  Chromophobe carcinoma: hypodiploid with loss of chromosomes 1. 6. Other associated genes include TRC8.6:1 and has been decreasing over the last decade. RCC accounted for 3777 deaths in the UK in 2006. Also. RCCP3. The following system can be used to classify these tumors:  Clear cell renal cell carcinoma (VHL and others on chromosome 3)  Papillary renal cell carcinoma (MET.ANGGA NUGRAHA . a hereditary leiomyoma RCC syndrome and Birt-Hogg-Dubé syndrome. Hypertension and a family history of the disease are also risk factors. HNF1A. 17. Array-based karyotyping performs well on paraffin embedded tumors and is amenable to routine clinical use. In Europe the incidence of RCC has doubled in the period from 1975 to 2005. The reasons for this are not clear. 13. gasoline has not been shown to be consistently associated with RCC risk. 16. palpation of the abdomen may reveal the presence of a mass or an organ enlargement. and RCC17. Patients with certain inherited disorders such as von Hippel-Lindau disease. Epidemiology The incidence of renal cell cancer has been rising steadily. Exposure to asbestos. and an anamnesis (the detailed medical review of past health state) to evaluate any risk factors.  Clear cell carcinoma: loss of 3p  Papillary carcinoma: trisomy 7. It will frequently have an irregular or lobulated margin. The first steps taken in order to diagnose this condition are observing any of the signs and symptoms. Diagnosis An accurate diagnose may be difficult to establish given that the early stages of renal cancer are asymptomatic.0918011103 Constipation Hypertension (high blood pressure) resulting from secretion of renin by the tumour (30% of cases) Elevated calcium levels (Hypercalcemia) Stauffer syndrome . If the ultrasound shows a mass or cyst. Blacks have a slightly higher rate of renal cell cancer than whites. a subsequent abdominal CT is the optimal test for diagnosis and staging. and some contain macroscopic fat (likely due to invasion and encasement of the perirenal fat). the main diagnostic tool for detecting renal cell carcinoma is ultrasound of the kidneys. 21 Array-based karyotyping can be used to identify characteristic chromosomal aberrations in renal tumors with challenging morphology.paraneoplastic. non-metastatic liver disease Night Sweats Severe Weight Loss Patients may also experience the following symptoms:  Recurrent fevers which occur in 9% of the patients  Cold intolerance  Back pain  Chronic fatigue  Leg and ankle swelling  Loss of appetite Classification Micrograph of chromophobe renal cell carcinoma oncocytic variant. polycyclic aromatic hydrocarbons. female 1820. OGG1.

The body of the tumor shows large blood vessels that have walls composed of cancerous cells.0918011103 Renal cell carcinoma may also be cystic. their cytoplasm appear "clear". has shown promise. hemorrhage and scarring. and are atypical. but well vascularized. This is not completely accurate. around 12-20% in most series. most of the tumors contain a mixture of cells.1 years for stage III and 1. Percutaneous biopsy can be performed by a radiologist using ultrasound or computed tomography to guide sampling of the tumor for the purpose of diagnosis by pathology. The stroma is reduced. Recent studies have brought to attention that the type of cancerous cells and the aggressiveness of the condition are closely related. such as in the lungs. or targeted therapy. which frequently contains zones of necrosis. 51% for stage II. there are new experimental treatments. Staging The staging of renal cell carcinoma is the most important factor in predicting its prognosis. 30% of renal cell carcinomas have spread to the ipsilateral renal vein. The renal cell carcinoma may present reddened areas where blood vessels have bled. At diagnosis. including cytoreductive surgery. often into the lymph nodes or the main vein of the kidney. then it must be treated with adjunctive therapy. biologic. Treatment If it is only in the kidneys. In early stage cases. but does respond well to immunotherapy with interleukin-2 or interferon-alpha.0 years for stage II. the cells that make up a renal carcinoma may be clear. However this is not routinely performed because when the typical imaging features of renal cell carcinoma are present.1 years for stage IV. and cysts containing watery fluids. it can use overall stage grouping into stage I-IV. the prognosis is generally poor. 5. 3. involvement of lymph nodes (N) and metastases (M) are classified separately.7 years for stage I. though the current complete remission rate with these approaches are still low. with or without spread into the large veins leading any of the from the kidney to the heart. 22% for stage III and 4.ANGGA NUGRAHA . where the size and extent of the tumour (T). it can be cured roughly 90% of the time with surgery. but without spread to any lymph nodes or other organs. the nuclei remain in the middle of the cells. and the cellular membrane is evident. Tumor that has spread directly through the fatty tissue and the fascia ligament-like tissue that surrounds the kidney. No lymph node involvement Stage I or metastases to distant organs. or brain. and 5-10% has continued on into the inferior vena cava. The same study estimated the median survival time to be 7. As there are several benign cystic renal lesions (simple renal cyst. multilobulated tumor in the renal cortex. Recent trials are testing newer agents. with eosinophilic cytoplasm. Most recently. Histopathology The gross and microscopic appearance of renal cell carcinomas is highly variable. A classification system for cystic renal lesions that classifies them based specific imaging features into groups that are benign and those that need surgical resection is available. hemorrhagic renal cyst. polycystic kidney disease). bone. following Tumor with spread to fatty tissue around the kidney and/or spread into the large veins leading from the kidney to the heart. cryotherapy and surgery are the preferred options. and limited to the kidney. mixed clear and granular or sarcomatoid or spindle type. tubules or nests. treatment with tyrosine kinase inhibitors including nexavar. The tumor compresses the surrounding parenchyma. Gross examination often shows a yellowish. which attempts to induce the body to attack the remaining cancer cells. multilocular cystic nephroma. Prognosis A study in Turkey that used the 1997 AJCC staging system estimated the five year survival rate to be 90% for stage I. papillae. resembling normal tubular cells. the possibility of an incorrectly negative result together with the risk of a medical complication to the patient make it unfavorable from a risk-benefit perspective.6% for stage IV. Some cells may be smaller. The following describes a typical clear cell carcinoma. polygonal and large. Stage II Tumor of any size with involvement of a nearby lymph node but no metastases to distant organs. pazopanib. Immunotherapy. The most aggressive stage of renal cancer is believed to be the one in which the tumor is mixed. Tumor larger than 7. [37] However.0 cm but still limited to the kidney. Watchful waiting Small renal tumors (< 4 cm) are treated increasingly by way of partial nephrectomy when possible. For those that have tumor recurrence after surgery. Also. it may occasionally be difficult for the radiologist to differentiate a benign cystic lesion from a malignant one. RCC is resistant to chemotherapy and radiotherapy in most cases. Light microscopy shows tumor cells forming cords. producing a pseudocapsule.[33] Staging can follow the TNM staging system. containing both clear and granular cells. Tumor of this stage Stage III may be with or without spread to fatty tissue around the kidney.[39][40][41] Most of these small renal masses manifest indolent biological behavior with excellent prognosis. No lymph node involvement or metastases to distant organs. and rapamycin have shown promise in improving the prognosis for advanced RCC since 2004. More centers of excellence are incorporating needle biopsy to 9 . Renal cell carcinoma does not generally respond to chemotherapy or radiation. with the 1997 revision of AJCC described below: Tumor of a diameter of 7 cm (approx. which is about 40% of cases. which is the most common type. If it has spread outside of the kidneys. Also. Stage IV Involvement of more than one lymph node near the kidney any of the Involvement of any lymph node not near the kidney following Distant metastases. 2 3/4 inches) or smaller. The clear cells are thought to be the least likely to spread and usually respond more favorably to treatment.Because these cells accumulate glycogen and lipids. granular.

cytoreductive nephrectomy is 10 . Bevacizumab. Typically a biopsy is taken at the time of treatment. Metastatic renal cell carcinoma presents a special challenge to oncologists. patients with comorbidities and in poor surgical candidates. Medications for advanced or metastatic cases RCC "elicits an immune response. cohesion. Sunitinib (an oral. and 5 year survival for patients with metastatic renal cell carcinoma is between 5-15%.as response rates are very low. usually managed by radiologists. Intraoperative ultrasound may be used to help guide placement of the freezing probes. and temsirolimus. have been approved by the U. Please help improve it or discuss these issues on the talk page.though it is much improved if metastatectomy and nephrectomy to remove all visible disease is performed. In cases of known metastases. WikiProject Medicine or the Medicine Portal may be able to help recruit one. The metastatic stage of the renal cell carcinoma occurs when the disease invades and spreads to other organs. and Temsirolimus are described in a different section Vaccine Cancer vaccines. such as cancer vaccines and interleukin-2 (IL-2). Tagged since March 2010. It is most likely to spread to neighboring lymph nodes. such as Sunitinib and Sorafenib.  It needs additional references or sources for verification. small renal tumors may be monitored carefully with serial imaging. ultrasound. or the brain.often just 5-15%.S.[43] as well as resection of a solitary metastatic lesion. which are small-molecule inhibitors of proteins. pazopanib. which is to destroy proteins that promote inappropriate vascularization. Therefore. but As of 2008 phase 3 trials have not been published. For small exophytic lesions that do not extensively involve the major vessels or urinary collecting system. Sunitinib appears to offer greater potency against advanced RCC. as about 70% of patients with renal cell carcinoma develop metastases during the course of their disease. image-guided therapies. Treatment with tyrosine kinase inhibitors including Nexavar. Another strategy is to restore the function of the VHL gene. an antibody to VEGF. and then destroying the tumor with heat (radiofrequency ablation) or cold (cryotherapy). Tagged since January 2010. Surgery Surgical removal of all or part of the kidney (nephrectomy) is recommended. This sort of procedure involves placing a probe through the skin and into the tumor using real-time imaging of both the probe tip and the tumor by computed tomography. and rapamycin have shown promise in improving the prognosis for advanced RCC since 2004. IL-2 has produced "durable remissions" in a small number of patients. In cases where the tumor has spread into the renal vein. but who are not good candidates for a surgical procedure." This has encouraged a strategy of using immunomodulating therapies. multi-targeted (RTK) inhibitor) and sorafenib both interfere with tumor growth by inhibiting angiogenesis as well as tumor cell proliferation. which occasionally results in dramatic spontaneous remissions. Percutaneous therapies Percutaneous. retroperitoneal lymph nodes. A month later. have shown promising results in phase 2 trials for treatment of renal cell carcinoma. However.  It may need copy editing for grammar. Their use can not be recommended for the treatment of patients with metastasized RCC. Sorafenib (Nexavar). even if metastases are not removed. has significantly prolonged time to progression. issues of tumor immunosuppression and lack of identified tumor-associated antigens must be addressed before vaccine therapy can be applied successfully in advanced renal cell cancer. sorafenib (Nexavar). small-molecule. Mannitol can also be administered to help limit damage to the kidney. Sunitinib (Sutent). Laparoscopic cryotherapy can also be done on smaller lesions.0918011103 confirm the presence of malignant histology prior to recommending definitive surgical extirpation. F. long-term follow-up is crucial to assess completeness of tumour ablation.ANGGA NUGRAHA . This may involve temporarily stopping blood flow to the kidney while the mass is removed as well as renal cooling with an ice slush. Chemotherapy Most of the currently available cytostatics are ineffective for the treatment of RCC. beyond which the risk of distant spread (metastases) is about 5%. The use of Tyrosine Kinase (TK) inhibitors.A. This is usually done through an open incision although smaller lesions can be done laparoscopically with or without robotic assistance. a partial nephrectomy (also referred to as "nephron sparing surgery") can be performed. the bones. such as TroVax. are being offered to patients with localized tumor. and possibly the right atrium. as well. Sunitinib (Sutent) was approved as well.D. to reproduce this response. Two freeze/thaw cycles are then performed to kill the tumor cells. the lungs. In the elderly. This may include removal of the adrenal gland. but with substantial toxicity. a protein kinase inhibitor. style. Surgery is increasingly performed via laparoscopic techniques. tone or spelling. Metastatic renal cell carcinoma This section has multiple issues. These modalities are at a disadvantage compared to traditional surgery in that pathologic confirmation of complete tumor destruction is not possible. and possibly tissues involved by direct extension (invasion) of the tumor into the surrounding tissues. or even magnetic resonance imaging guidance. Tagged since January 2010. this portion of the tumor can be surgically removed.  It is in need of attention from an expert on the subject. Most clinicians conservatively follow tumors up to a size threshold between 3–5 cm. inferior vena cava. perhaps because it inhibits more receptors than sorafenib. These have the advantage of being less of a burden for the patient and the disease-free survival is comparable to that of open surgery. As the tumor is not removed followup is more complicated (see below) and overall disease free rates are not as good as those obtained with surgical removal. was FDA approved in December 2005 for treatment of advanced renal cell cancer. the liver. Kidneys are sometimes embolized prior to surgery to minimize blood loss.and most responses are short lived. surgical resection of the kidney ("cytoreductive nephrectomy") may improve survival.

for lung metastases.and at least 1 study has supported the use of cytoreductive nephrectomy in "some cases" of metastatic renal cell carcinoma. capillary leak syndrome. Systemic symptoms occur in some people with metastatic renal cell carcinoma. diarrhea. including central venous catheter infections. Lyme disease [in the case of unexplained malaise. bruit. rigors. speech problems. ALT is a form of outpatient adoptive immunotherapy utilizing autologous ex vivo activated T-cells accompanied by high dose cimetidine. less severe illness. Also. in order to prevent any new (metastatic) cancer growths from re-appearing. cortical blindness. elevations in AST and ALT. nexavar. septicaemia. dermatitis. thyroiditis. nekrosis dan disertai daerah-daerah yang mengeras. mouth sores. sutent. Radiotherapy is used in bone metastases from renal cell carcinoma to reduce pain and lower the risk of pathologic fracture. Massa tumor berwarna kuning keemasan. vasodialation. and coma. Given that many diseases can cause these symptoms. and bone pain]. sutent) have been met with little success. Other side effects include abdominal pain.which severely limits possible effective adjuvant therapy.ANGGA NUGRAHA . renal failure. There does appear to be some evidence that if there cancer is incompletely resected (positive surgical margins. reduced organ perfusion. in patients with brain metastases. headache. acidosis. and seizures. and include anorexia. targeted therapies including torisel. psychosis.S. Brain metastases produce diplopia. and vomiting. Unlike most other cancers. and include ataxia. thrombocytopenia. angina. about half of patients that respond have long term disease free survival. stiffness. and bacterial endocarditis.but data is lacking on that as well. However. arthritis. ataxia. chemotherapy. and anaemia. nephritis. Adjuvant therapy in renal cell carcinoma Adjuvent therapy is typically a secondary treatment that is administerted after all visible cancer has either been surgically excised. Symptoms of metastatic renal cell carcinoma are often mistaken for other. Proleukin also can result in lethargy and somnolence. weight loss. This is the sixth drug to be approved for metastatic renal cell carcinoma since 2005. or biologic therapies (i. Neurological side effects can also occur. Interleukin-2. has been the standard of care since the 1990s in metastatic renal cell carcinoma. Interleukin-2 can also worsen pre-existing autoimmune diseases.adrenal involvement. director of the office of oncology drugs at the U.Pada pembelahan massa tumor. renal cell carcinoma is resistant to most cytotoxic and cytostatic agents. The last 3–5 years have seen dramatic improvements in treatment for those with metastatic renal cell carcinoma. Food and Drug Administration (FDA).e. Pada pemeriksaan arteriografi tampak pembuluh-pembuluh darah yang abnormal pada daerah ginjal. despite these improvements in therapy. biologic. any other neoplastic disease. Richard Pazdur. for liver metastases. diabetes mellitus. fever. Recently. nexavar. abdominal pain. and abnormal chest radiograph. and to palliate symptoms of metastatic disease to the liver. pulmanary. Makroskopis Tampak massa tumor yang menembus sel korteks ginjal. altered mental status. myesthinisa gravis. Skenario Seorang laki-laki berumur 40 tahun mengeluh buang air kecil warna merah di sertai panas badan dan tekanan darah tinggi. fatigue. hallucinations. locomotor ataxia. 11 . inflammatory bowel disease. radiotherapy. and other chronic infections. hepatic. and pathologic fracture. radiated or otherwise eliminated.the side effects of interleukin-2 are very severe. asthenia. Trials of "cancer vaccines". It is not known whether or not detecting metastatic renal cell carcinoma earliar improves survival or response to treatment. immunotherapy. fatigue. which can result in myocardial infarction. There have also been a number of trials of Autolymphocyte therapy (ALT) which have shown varying degrees of efficacy. adrenals. and immunologic agents are being researched in the treatment of metastatic renal cell carcinoma. cardiac arrhythmias. Differential diagnoses include leukaemia. and malaise.and currently the standard of care for completely resected high-risk renal cell carcinoma is close observation with no other therapy. However.exacerbation of scleroderma. as although response rates are low [7-16%]. personality changes. tachycardia. including decreased neutrophil function. edema. MD. Also.citing improved response rates to interleukin-2 immunotherapy and modestly prolonged survival. dyspnea. and other autoimmune diseases have been reported. Currently. increased risk of dissemenated infection. The use of non-specific cytokines has so far been shown to be ineffective. fever of unknown origin.and include: for bone metastases. tampak daerah perdarahan. vomiting. and all are now approved for the treatment of metastatic renal cell carcinoma. There is currently no established adjuvant therapy for renal cell carcinoma. and some appear promising. pulmonary failure requiring intubation. overall survival in metastatic renal cell carcinoma remains quite poor. Radiotherapy and chemotherapy have less of a role in therapy of renal cell carcinoma then in other malignancies. The re-appearance of cancer typically occurs after micro-cancerous cells remain in the body after the primary cancer has been removed.0918011103 sometimes used in the treatment of metastatic renal cell carcinoma. pain. hypotension. malaise. dyspnea. patients must be in good health with normal cardiovascular. and some of these patients may be cured of their disease. but they are still sometimes used in treatment of metastatic renal cell carcinoma.and neurological function to be treated with interleukin-2. tumor vaccines and chemotheraputic. extensive testing is typically required to diagnose metastatic renal cell carcinoma. loss of appetite.vena caval involvement) radiotherapy reduces the risk of invasive local disease. jaundice. cough. and gastrointestinal bleeding. or lungs from renal cell carcinoma. votrient [pazopanib] was approved for the treatment of metastatic renal cell carcinoma in October 2009. and bevacizumab have been developed. vertigo. although there have been a number of clinical trials exploring the effectiveness of various potential treatments. if interleukin-2 therapy is not discontinued lethargy may progress to coma.

Mikroskopis penderita tumor Grawitz Gambar . mikroskopis penderita tumor grawitz Gambar. Gambar atau buat foto mikroskopis. Gross ginjal penderita tumor Grawitz Gambar .ANGGA NUGRAHA .0918011103 Gambar. Mikroskopis penderita tumor Grawitz Kesimpulan Karsinoma sel renal Tugas 1. gros ginjal penderita tumor Grawitz Mikroskopis Pada pemeriksaan mikroskopis masih tampak perubahan dari ginjal menjodi massa tumor. Gambar. beri keterangan gambar yang telah dibuat! Karsinoma sel renal tersebut di atas berasal dari sel? Bedakan antara karsinoma sel renal dan transitional cell carcinoma? 12 . Sel-sel tumor tampak cerah atau bergranuler dengan inti yang hiperkromatis. Tampak pula focus-focus perdarahan dan serbukan sel radang limfosit. 2. 3.